Editorial Credits/ Crédits éditorials

Subscription Rates /Prix d'abonnements

Advertising Rates / Tarifs publicitaires (PDF)

Guest Editorial
Psychiatric Epidemiology: Vibrant Art and Penetrating Science
Elliot M Goldner
(PDF)

In Review
The National Survey of Mental Health and Well-Being in Australia: Impact on Policy
Scott Henderson
(PDF)

Child Psychiatric Epidemiology and Canadian Public Policy-Making: The State of the Science and the Art of the Possible
Charlotte Waddell, David R Offord, Cody A Shepherd, Josephine M Hua, Kimberley McEwan
(PDF)

Review Papers
Prevalence and Incidence Studies of Schizophrenic Disorders: A Systematic Review of the Literature
Elliot M Goldner, Lorena Hsu, Paul Waraich, Julian M Somers
(PDF)

Original Research
Sleep Quality in Chronic Pain Patients
Kemal Sayar, Meltem Arikan, Tulin Yontem
(PDF)

Psychiatric Disorders and Use of Mental Health Services by Ontario Women
Sarah Frise, Allan Steingart, Margaret Sloan, Michelle Cotterchio, Nancy Kreiger
(PDF)

Counsellors in Primary Care: Benefits and Lessons Learned
Nick Kates, Anne-Marie Crustolo, Sheryl Farrar, Lambrina Nikolaou
(PDF)

Neuropsychological Performance in DSM-IV ADHD Subtypes: An Exploratory Study With Untreated Adolescents
Marcelo Schmitz, Luciana Cadore, Marcelo Paczko, Letícia Kipper, Márcia Chaves, Luis A Rohde, Clarissa Moura, Márcia Knijnik
(PDF)

Brief Communication
Benefits of Switching From Typical to Atypical Antipsychotic Medications: A Longitudinal Study in a Community-Based Setting
Peter E Cook, Joel O Goldberg, Ryan J Van Lieshout
(PDF)

Homicide in the Canadian Prairies: Elderly and Nonelderly Killings
AG Ahmed, Robin PD Menzies
(PDF)

Book Reviews
(PDF)

History of Psychiatry
Reviewed by
Sean P Beingessner

General Psychiatry
Reviewed by
Michael F Myers

Chronic Fatigue Syndrome
Reviewed by
Ellie Stein

Geriatric Psychiatry
Reviewed by
Matt Robillard

Psychiatrie générale
Reviewed by
Pierre Doucet

Letters to the Editor
(PDF)

Categorizing Continuous Variables

A Case of Neuroleptic Malignant Syndrome With Clozapine and Risperidone

Zonisamide Treatment of Bipolar Disorder: A Case Report

Combined Use of Atypical Antipsychotics and Cognitive-Behavioural Therapy in Schizophrenia

Distress Levels in Patients With Premenstrual Dysphoric Disorder

Alcoholism, Seasonal Depression, and Suicidal Behaviour

Recruiting Residents Through a Summer Medical Student Program

A Case of Paroxetine-Induced Galactorrhea

Beyond Principal-Component Analysis of the Positive and Negative Syndrome Scale in Patients With Schizophrenia

Olanzapine-Induced Hair Loss

Paternal Age as a Risk Factor

All studies except the VTSABD and the QCMHS reported patterns of service use. As Table 4 shows, only 16% to 27% of children with mental disorders received specialized mental health services from community mental health clinics, private practitioners, or related social agencies (although each study used somewhat different criteria to define these services). According to the OCHS, however, 59% of children with mental disorders received primary health care, and 24% received special education services for these problems (18). The BCMHS reported that 40% of children with mental disorders received primary health care, and 50% received education services for mental health problems (31). The education system was described as “the major player” in the system of care for children with mental health problems in the GSMS: for most children who received any mental health care, the school system was the sole provider (23, p 152).

The State of the Science: Unresolved Research Issues

Based on this review, it appears that progress has been made in child psychiatric epidemiology, particularly with the use of standardized assessments that include measures of impairment and multiple informants. Data have now been collected from various settings, and consistent findings are emerging. In particular, the finding that 14% of children have clinically important mental disorders is robust, based on the 6 studies reviewed here. Concerning associated factors such as sex and age, boys are at greater risk overall, although risks for boys are greater when they are younger, and risks for girls are greater when they are older. Low family income is linked with significantly higher rates of mental disorders for all children. More research is required to establish causation regarding these and other associated factors. With patterns of service use, it appears that most children with mental disorders do not receive specialized mental health services for their mental health problems, although many receive primary health care and school services.

Despite progress in the research, there are 3 unresolved methodological issues in child psychiatric epidemiology that mitigate its usefulness for policy-makers. The first issue involves defining thresholds for what constitutes a clinically important disorder, or “caseness.” Essentially, epidemiological studies must identify children with disorders on the basis of having both significant symptoms and significant impairment (7,13). The use of standardized protocols has improved consistency in assessing symptoms, but there is still no agreement on how to assess impairment or on how to combine measures of both symptoms and impairment (3). This inconsistency contributes to the considerable variation in overall prevalence rates (10% to 20%) found among studies, as Table 1 illustrates.

The use of informants is a second unresolved methodological issue. Most authors agree that multiple informants should be used in child psychiatric epidemiological studies, including children (particularly for older age groups), parents, and teachers (13). Yet, poor agreement among informants is frequently reported (18,21,28). Children, for example, typically report higher rates of internalizing symptoms, such as anxiety and depression, while parents report higher rates of externalizing symptoms, such as conduct problems (34). The basic identification of child psychiatric disorders appears to be greatly influenced by informants’ context and perceptions (35). However, as Table 1 illustrates, there is not yet consensus on how to reconcile, or even report, conflicting prevalence data obtained from different informants. This lack of consensus also contributes to variation in prevalence rates reported between studies.

A third unresolved methodological issue in child psychiatric epidemiology involves the lack of standardization among studies regarding which data are collected and how results are reported (3,13). As Table 2 illustrates, each study assessed different disorders or groups of disorders. Some studies were also more comprehensive than were others in terms of the number of mental disorders assessed. Comparing overall prevalence rates then becomes problematic. For instance, the GSMS assessed more disorders than did other studies and, as a result, may report higher overall prevalence rates than do studies assessing fewer disorders (24). As Tables 3 and 4 illustrate, each study also collected and reported data on different associated factors and service-use variables. More consistency in collecting and reporting data would greatly help policy-makers, as well as other researchers, to interpret research findings.

In addition to these 3 unresolved methodological issues, several important questions remain unanswered in the current child psychiatric epidemiological research, particularly concerning associated factors and patterns of service use. The issue of diversity regarding First Nations and other cultural groups has not been adequately addressed (3). Little is known about the prevalence of mental disorders in younger children (35). Prospective studies still need to be conducted to better understand the role of development, comorbidity, and prognosis (7,36,37). Prospective studies are also needed to determine which associated factors play a causal role in the onset of disorders (38). Finally, patterns of service use are poorly understood. That most children with mental disorders do not receive specialized mental health services but may receive primary health care and school services has significant implications for service planning and thus merits further study (3).

Newer studies such as the GSMS are beginning to address some of these unresolved methodological issues and unanswered questions. The GSMS is assessing children longitudinally. It incorporates structured measures of both symptoms and impairment, using multiple informants. It is also examining different cultural groups and patterns of service use in different sectors (23,24,26). The OCHS follow-up will address many of the same issues in Canada (Boyle MH, Offord DR, Racine Y, personal communication, 2002).

Ultimately, policy-makers need to receive clear messages about which research findings merit action. Ensuring that methodological issues and unanswered questions are resolved are good first steps. However, the communication of research findings must also be improved (an overarching issue in child psychiatric epidemiology, as well as in many other health fields). Typically, the results of child psychiatric epidemiological studies are reported mainly in academic journals in formats that are relatively inaccessible to policy-makers. For policy-makers to appropriately apply research findings, they must first be communicated in user-friendly formats that better suit policy-makers’ needs and environments (11). To raise public awareness about the importance of children’s mental health, child psychiatric epidemiological research findings also need to be communicated better to popular media and child advocacy groups. Perhaps most important, more research needs to be conducted in closer partnership with policy-makers to help ensure better relevance and dissemination.

The Art of the Possible: Implications for Policy-Making

Child psychiatric epidemiology is crucial for sound policy development in the public sector. Researchers need to do their part by conducting high-quality research and ensuring better communication of research findings to policy-makers and others. The findings of recent studies, however, also pose a distinct challenge to policy-makers.

Most important, policy-makers must come to terms with the high numbers of children involved. Clearly, there is a policy shortfall, given that 14% of children, or 1.1 million in Canada, likely have clinically important mental disorders and that most of these children do not receive specialized mental health services. However, increased investment in clinical services alone is unlikely to achieve a marked reduction in the burden of suffering (12). At a minimum, the basic human resource and training issues preclude reaching all children in need with clinical services (39). Complicating matters further, evidence is still lacking on effectiveness for many clinical treatments (6).

Instead, tackling the burden of suffering likely requires investing in population (or public) health strategies, in addition to clinical services. Population health models focus on whole populations, or on groups within populations, and on improving family incomes, social supports, early child development, and other nonmedical determinants of health for all children (9,10). Conversely, clinical service models emphasize the provision of diagnostic and treatment services for individuals who have disorders. Historically, population health and clinical models have been seen as entirely distinct from one another (40). Recently, however, consensus has emerged that the 2 approaches can be complementary and that both are needed to improve health outcomes (41).

Offord and colleagues argued for multifaceted approaches in children’s mental health, taking both population health and clinical considerations into account (12). They suggested that lowering the burden of suffering can only be achieved with a rational mix of universal programs to promote health for all children, targeted preventive interventions for children at risk, and clinical services for children with severe disorders. They argued that all 3 levels of intervention are necessary and that synergies may exist between the levels. For instance, universal programs involving primary health care and early child development may “till the soil,” so that targeted programs can be more effective, which may in turn reduce the need for specialized clinical services. Jenkins agreed that mental health policies should be multifaceted (4). She proposed that community-based programs and services, including schools, should focus on mental health promotion and prevention, while primary health care practitioners should handle most basic mental health problems, and specialists should focus on supporting primary care and providing services to those with the highest needs.

In coming to terms with the high numbers of children involved, policy-makers must ensure the effective and efficient use of public funds. Recent reports from major American organizations, such as the National Institute of Mental Health and the United States Surgeon General, have highlighted the numerous administrative problems that hamper children’s mental health service delivery efforts with regard to effectiveness and efficiency (5,6). Problems include fragmentation among children’s mental health and related services, discipline insularity, lack of evidence-based practice, and inability to monitor outcomes (5,6,39). These recent reports suggest that coordination is urgently needed among the various sectors involved with children. These sectors may include (depending on the child’s developmental stage and need for services) public health, primary care, early child development, social support, school, specialized mental health, child protection, justice, hospital, and other programs and services. These reports discuss the need to promote interdisciplinary approaches and they advocate for redirecting public funds toward interventions that have demonstrated effectiveness, based on the best available research evidence. In addition, the inability to monitor outcomes over the long term hampers planning in most jurisdictions. Attention to all these issues is imperative if children’s mental health outcomes are to improve.

Ultimately, to guide their efforts at improving mental health outcomes for children, policy-makers need timely and relevant research information that is communicated clearly on an ongoing basis. Researchers need to do their part to facilitate this process. By establishing ongoing collaborative partnerships with researchers, policy-makers can also contribute to improved timeliness and relevance by ensuring that their concerns are incorporated into the design, conduct, and dissemination of the research at provincial and national levels. Meanwhile, policy-makers have a responsibility to ensure that the mechanisms are in place within their organizations to work effectively with researchers and to apply research information as it becomes available.

Conclusions

Returning to the art of the possible, child psychiatric epidemiology provides much in the way of rational evidence, but public policy-making involves many overriding nonrational political processes, as well. Although there will always be limits to the usefulness of any research evidence in policy-making, the science of epidemiology has the potential to help policy-makers by describing children’s mental health needs in the population and by providing the basis for long-term strategies to improve outcomes. More pragmatically, the data on prevalence rates and patterns of service use may be persuasive in obtaining additional resources for children’s mental health in times of fiscal restraint. Similarly, these data can provide the rationale for balanced responses when interest groups lobby for a single disorder or for a single service approach.

Researchers can make child psychiatric epidemiology more useful to policy-makers by resolving the outstanding issues that limit the state of the science. Meanwhile, policy-makers in children’s mental health must grapple with a high burden of suffering that demands multifaceted public policy strategies in response. Moreover, both researchers and policy-makers can benefit from forming better partnerships to ensure ongoing research relevance, dissemination, and application.

The common goal of researchers and policy-makers is to reduce the burden of suffering associated with children’s mental disorders. In contrast to Bismarck, Galbraith commented: “Politics is not the art of the possible. It consists in choosing between the disastrous and the unpalatable” (43). If Galbraith is right, at the very least, child psychiatric epidemiology can assist policy-makers to navigate between the unpalatability of diverting resources from competing priorities and the disaster of not investing enough in children’s mental health. Otherwise, the burden of suffering associated with children’s mental disorders in Canada will remain unacceptably high.

1 | 2 | 3 | 4