The
Canadian Journal of Psychiatry
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| Volume
47 |
Ottawa,
Canada, November 2002 novembre
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Number
9
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Guest Editorial
Psychiatric Epidemiology: Vibrant Art and Penetrating Science
Elliot M Goldner MD, MHSc, FRCPC1
Click here for author affiliations
This issue of The Canadian Journal of Psychiatry includes an In Review
focus on psychiatric epidemiology by invited expert contributors. It also
introduces the first in a series of articles that, over several months,
will discuss the results of in-depth examination of the prevalence and
incidence of mental disorders. One might puzzle over the value of such
an epidemiological extravaganza.
On the surface, psychiatric epidemiology might appear to be little more
than a hapless, yawn-inducing exercise in bean-counting. Yet, a gentle
scratch over the numbers, rates, and proportions exposes abundant intriguing
and illuminating insights into many of the most important questions facing
psychiatry. Moreover, epidemiology is the basic science of public health
(1). Applied to increase understanding of Canada’s psychiatric services,
it may enhance the effectiveness of preventive efforts and strengthen care
delivery to people affected by mental disorders.
Many of medicine’s greatest triumphs have been accomplished through the
application of epidemiologic methods to solve etiological mysteries and
produce breakthroughs in prevention and treatment (2). In the past, smallpox,
diphtheria, typhoid, and cholera were puzzling diseases that devastated
populations. Their causes were unknown, and no effective treatments could
be found. In each case, epidemiological methods led to effective prevention
or treatment (1,3). If we once considered such infectious epidemics to
be pages in history with little relevance to contemporary health care,
we have been utterly mistaken and made poignantly aware over recent decades
by the emergence of the tragic AIDS pandemic and the profound desolation
that has arrived in its wake.
Over the past century, epidemiological studies have led to substantive
advancements in our understanding of cancer, heart disease, diabetes mellitus,
HIV-related illness, and countless other medical and surgical conditions.
Thankfully, psychiatric disorders have not been overlooked. A wealth of
information has been mined as a result of thoughtfully designed and carefully
executed explorations in psychiatric epidemiology. Moreover, some of the
finest studies have been done in Canada.
The renowned Stirling County Study (4) set a gold standard for studies
in psychiatric epidemiology throughout the world. This remarkable exploration
of a community in Nova Scotia was designed and initiated by Professor Alexander
Leighton in 1948. Now directed by Professor Jane Murphy and her colleagues,
the study continues after 50 years to produce rich insights into the mental
health (and illness) of Canadians and into the importance of social, economic,
and historical factors (5). It remains a beacon to illuminate the human
experience, set within the context of a living and evolving Canadian community.
Many other notable achievements have been made in Canadian psychiatric
epidemiology, and here, I mention but a few. Together with their colleagues
in Alberta, Professor Roger Bland and Professor Steve Newman have undertaken
an extensive series of epidemiologic studies that answer a multiplicity
of questions about the extent and nature of psychiatric conditions (6–8).
In Ontario, Professor Dan Offord, Professor Paula Goering, Professor Michael
Boyle, and Dr Elizabeth Lin, along with several other colleagues, completed
large-scale community surveys and examined met and unmet need for mental
health services and supports (9,10). In La Belle Province, Professor Jean-Jacques
Breton, Dr Lise Bergeron, Dr Jean-Pierre Valla, and their colleagues, with
the collaboration of Santé Québec, undertook meticulous studies of mental
disorders among children (11). People living across the entire country
are regularly surveyed in carefully designed cycles, and the precious information
obtained is made available to researchers to promote its utility and application
to important problems. At this very time, cycle 1.2 of the Canadian Community
Health Survey, funded through Health Canada’s Health Information Roadmap
Initiative, is underway, and with the assistance of the Canadian Academy
of Psychiatric Epidemiology, important mental health survey data are being
carefully collected and collated through the expert ministrations of Statistics
Canada (12).
Here are some examples of important questions in psychiatry currently being
addressed through epidemiological investigation: Are incidence rates (new
episodes) of schizophrenia increasing or decreasing, and what factors appear
to affect these rates? During their school-age and adolescent years, what
differences in risks for specific psychiatric disorders face girls, compared
with boys, and what factors might be implicated? Does late life bring improved
or worsened levels of mental health for most of the population, and what
are the consequences for health care delivery? Are the lower rates of psychiatric
disorder reported among Asian populations valid or attributable to differences
in interpretation or conceptualization? Each of the preceding examples
is touched upon in articles found in this issue.
The first In Review paper summarizes some of the extensive findings of
the most recent and state-of-the-art survey of mental health and illness,
the Australian National Survey of Mental Health and Well-Being. Although
this accomplishment has involved the efforts of many devoted researchers
and scholars “Down Under,” Professor Scott Henderson and Professor Gavin
Andrews are credited with much of its overarching design. Their statesmanship
in ensuring that this mammoth project was funded, supported, and seen through
to completion by government decision makers has been a critical factor
in its success. In his review, Professor Henderson highlights some key
findings of this national psychiatric epidemiological study and their implications
for the practice of psychiatry.
In the second In Review paper, a group of Canadian authors led by Dr Charlotte
Waddell and Professor Dan Offord review the findings of key epidemiological
studies addressing mental health and mental illness in childhood. A unique
feature of this paper is its attention to the effective translation of
such epidemiological findings to serve public policy-makers.
This issue also contains a systematic review of prevalence and incidence
studies of schizophrenia—the first of a planned Journal series addressing
major psychiatric disorders and highlighting implications for psychiatric
policy and practice. Systematic reviews such as these are considered to
hold potential for informing rational decision making in health care policy
and service development (13).
So, if you envision psychiatric epidemiology as a musty and irrelevant
production, I hope that in reading this issue you will discover, au contraire,
a vibrant art and penetrating science that continues to play an important
role in solving the critical questions facing us all.
References
1. Vetter N, Matthews I. Epidemiology and public health medicine. Edinburgh:
Churchill Livingstone; 1999.
2. Bhopal RS. Concepts of epidemiology: an integrated introduction to the
ideas, theories, principles, and methods of epidemiology. New York: Oxford
University Press; 2002.
3. Hardy A. The epidemic streets: infectious disease and the rise of preventive
medicine, 1856–1900. Oxford: Clarendon Press; 1993.
4. Murphy JM, Leighton AH. Repeated investigations of prevalence: the Stirling
County Study. Acta Psychiatr Scand 1989;Suppl 348:45–9. Discussion:167–78.
5. Murphy JM, Nierenberg AA, Laird NM, Monson RR, Sobol AM, Leighton AH.
Incidence of major depression: prediction from subthreshold categories
in the Stirling County Study. J Affect Disord 2002;68:251–9.
6. Newman SC, Bland RC. Incidence of mental disorders in Edmonton: estimates
of rates and methodological issues. J Psychiatr Res 1998;32:273–82.
7. Bland RC, Newman SC, Orn H. Health care utilization for emotional problems:
results from a community survey. Can J Psychiatry 1990;35:397–400.
8. Newman SC, Bland RC. Suicide risk varies by subtype of affective disorder.
Acta Psychiatr Scand 1991;83:420–6.
9. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, Racine YA.
One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years
of age. Can J Psychiatry 1996;41:559–63.
10. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use of mental
health services in Ontario: epidemiologic findings. Can J Psychiatry 1996;41:572–7.
11. Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J,
and others. Quebec child mental health survey: prevalence of DSM-III-R
mental health disorders. J Child Psychol Psychiatry 1999;40:375–84.
12. Beland Y, Bailie L, Catlin G, Singh MP. CCHS and NPHS—an improved health
survey program at Statistics Canada. http://data.library.ubc.ca/rdc/pdf/CCHSandNPHS.pdf
13. Gilbody SM, Petticrew M. Rational decision-making in mental health:
the role of systematic reviews. J Mental Health Policy and Economics 1999;2:99–106.
Authors
1. Associate Professor and Division Head, Mental Health Policy and Services,
Department of Psychiatry, University of British Columbia, Vancouver, British
Columbia.
Address for correspondence: Dr EM Goldner, Department of Psychiatry, University
of British Columbia, 2250 Wesbrook Mall, Vancouver, BC V6T 1W5
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