As part of the National Institute of Mental Health Epidemiologic Catchment Area study, 7954 respondents were questioned at baseline and 1 year later about sleep complaints and psychiatric symptoms using the Diagnostic Interview Schedule. Of this community sample, 10.2% and 3.2% noted insomnia and hypersomnia, respectively, at the first interview. Forty percent of those with insomnia and 46.5% of those with hypersomnia had a psychiatric disorder compared with 16.4% of those with no sleep complaints. The risk of developing new major depression was much higher in those who had insomnia at both interviews compared with those without insomnia (odds ratio, 39.8; 95% confidence interval, 19.8 to 80.0). The risk of developing new major depression was much less for those who had insomnia that had resolved by the second visit (odds ratio, 1.6; 95% confidence interval, 0.5 to 5.3). Further research is needed to determine if early recognition and treatment of sleep disturbances can prevent future psychiatric disorders.

Epidemiologic study of sleep disturbances and psychiatric disorders : an opportunity for prevention

• Utilization of health and mental health services by noninstitutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons In each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

Utilization of health and mental health services. Three Epidemiologic Catchment Area sites.

• A two-stage assessment of newly admitted outpatients at community mental health centers and primary medical care centers found the Center for Epidemiological Studies Depression Scale to be highly sensitive but relatively nonspecific when compared with assessments of depression by the Diagnostic Interview Schedule. Considerably higher than usual screening scores are recommended with both patient populations to improve the efficiency of the Center for Epidemiological Studies Depression Scale. The reasons for our finding that primary care clinicians underdiagnose depressive disorder while psychiatric clinicians overdiagnose it relative to the Diagnostic Interview Schedule include varied presentations by each sector's patients, differing clinical acumen, and factors affecting third-party reimbursement.

Assessing depression in primary medical and psychiatric practices.

Depressive symptoms and syndromes are common in the medically ill, although they are frequently unrecognized and untreated The authors review the epidemiology, differential diagnosis, clinical presentations, and response to treatment of this clinical problem They address such methodological issues in the current literature in this area as the advantages and limitations of standardized assessment measures and discuss treatment modalities for depression in the medically ill, including antidepressant medication and ECT This clinical problem warrants attention for a variety of reasons: its prevalence, associated morbidity, and treatability Elucidation of the mechanisms of depression in the medically ill may also contribute to a broader understanding of depression in other populations

Depression in the medically ill: An overview.

• The use of ambulatory and inpatient mental health and addiction services in the United States was estimated by means of data from the National Institute of Mental Health Epidemiologic Catchment Area Program standardized to the 1980 US census for adults 18 years of age and older. In a 1-year period, 22.8 million people used ambulatory services for mental or addictive disorder treatment; 54% of them had a current Diagnostic Interview Schedule/ DSM-III mental disorder and another 37.4% had a history of psychiatric disorder or significant psychiatric symptoms. A total of 325.9 million ambulatory visits were made, and the average number of visits per treated person per year was 14.3. There were 1.4 million persons admitted to at least one inpatient mental health or addiction setting during a 1-year period; 80% of them had a current DIS/ DSM-III disorder, and the remainder had a history of psychiatric disorder or significant psychiatric symptoms. Results were determined for specific mental and substance use diagnoses and service settings. Among treated persons with any mental or addictive disorder, the majority of visits were to mental and addictive disorders specialty settings (40.5% of total visits) and to support networks composed of friends, relatives, and self-help groups (37.0% of total visits). Although a large number of persons with mental and substance use disorders were seen in the general medical sector for mental health or addiction problems, they were seen less frequently and therefore made fewer visits to this sector (10.9% of total visits).

Use of Services by Persons With Mental and Addictive Disorders: Findings From the National Institute of Mental Health Epidemiologic Catchment Area Program

• Data are presented on the medical diagnoses and the type of general medical services used by persons with mental disorder diagnoses. This study is based on the 1975 experience of registrants in four medical programs contained in three organizational settings. The data on services were retrieved from each program's automated data system. The percent of patients seen in general medical departments receiving a mental disorder diagnosis ranged from 4.8% to 13.6% among the four programs. Patients with mental disorder diagnoses visit general medical departments from 11/2 to two times as frequently as patients without such diagnoses. Persons with a diagnosed mental disorder are likely to receive care for conditions in more International Classification of Diseases categories than other patients, and are more likely to receive a diagnosis for ill-defined conditions, signs, and symptoms.

Use of General Medical Care Services by Persons With Mental Disorders

• The division of responsibility between general medical staff and mental health specialists for care of persons with medical record diagnoses of mental disorders is documented in four organized health care settings. Rates of mental disorders identified in all departments ranged from 35.6 to 122.8 per 1,000 population. Specialty mental health departments treated most severe psychotic and personality disorders, plus transient situational disturbances, whereas neurotic, childhood behavior, and psychophysiological disorders received as much or greater attention in general medical departments. Mental disorder diagnoses were associated with greater patient use of general medical departments. However, joint specialty mental health/ general medical treatment of these patients was associated with lower general medical department visit rates in all settings. Such joint care was facilitated by the low average visit frequency use of mental health departments (2.2 to 8.9 visits per patient per year).

Specialist/Generalist Division of Responsibility for Patients With Mental Disorders

The authors present comparative data on the extent, nature, and impact of diagnosed mental disorder among children under 18 years of age seen during 1975 in four organized health care settings. Between 3.3% and 10.1% of the children seen were diagnosed as having a mental disorder in the study year, representing an annual prevalence of between 2.2% and 8.2% of the "covered" child populations. Transient situational disturbances, behavior disorders, and special symptoms were the most common diagnoses; the more severe disorders (organic brain disease, schizophrenia, and affective and other psychoses) accounted for less than 4% of all diagnosed mental disorder. Patients with diagnosed mental disorder used non-mental-health services (except those of pediatricians) appreciably more often than did patients without such a diagnosis.

Diagnosed mental disorder in children and use of health services in four organized health care settings

A follow-up assessing uses of findings from NIMH-supported research on health and mental health services utilization in organized health care settings revealed a range of applications across the study sites. The research, conducted primarily for national policy purposes, had an impact on study sites in the following areas: clinician perceptions and attitudes about mental health services provided; program directions; fiscal policy; and further related research. Research team composition and dissemination of study findings are discussed in relation to the applications made.

Edwin W. Hoeper

Papers

Use of General Medical Care Services by Persons With Mental Disorders

Specialist/Generalist Division of Responsibility for Patients With Mental Disorders

Diagnosed mental disorder in children and use of health services in four organized health care settings

Uses of ambulatory health/mental health utilization data in organized health care settings.