Guest Editorial
Psychiatric Epidemiology in Canada and
the CCHS Study
David L Streiner, PhD, CPsych1,
John Cairney, PhD2,
Alain Lesage, MD, FRCPC, MPhil3
The field of psychiatric epidemiology has a long, albeit often neglected, history—one that antedates the beginning of psychoanalysis. Klerman (1) and Weissman (2) have outlined 5 “generations” of epidemiologic research. The first dates back to 1885, when Jarvis (3) used hospital records and key informants in a Massachusetts town to determine the prevalence of treated and untreated mental disorders. The post–World War II era, which Weissman and Klerman both referred to as the golden age of psychiatric epidemiology, saw the famous Midtown Manhattan Study (4) in the US and the Stirling County Study in Canada (5). These studies and others were marked by large representative samples, high response rates, and the use of measures of overall impairment rather than the unreliable psychiatric diagnoses of the day.
The third era saw the introduction of structured clinical interviews, such the Present Status Schedule (6) in the US and the Present State Examination (7) in the UK; the Schedule of Affective Disorders and Schizophrenia (8); the Diagnostic Interview Schedule (9); the Composite International Diagnostic Interview (10); and numerous others. These interviews were accompanied by more objective and reliable criteria for the various diagnostic categories, first manifested in the Research Diagnostic Criteria (11) and leading eventually to the DSM-III and its later modifications. The Epidemiologic Catchment Area study (12), which involved over 18 000 adults in 5 sites and used the Diagnostic Interview Schedule, is perhaps the prime example of this generation of research.
The fourth generation melded the previous generation’s methodological developments—objective diagnostic criteria and structured interviews—with probability samples that encompassed an entire country, such as the National Comorbidity Study in the US (13) and the Community Health Survey in Canada (14). The fifth generation, which is still relatively young, focuses on children and adolescents.
Canada has been a major player in this area and has produced many leaders, including Alec Leighton and Jane Murphy in the Stirling County Study (5); Roger Bland with the Edmonton studies (15); the late Dan Offord, who led the Ontario Child Health Survey and the Ontario Health Supplement (16,17); and the researchers who conducted the Quebec Child Mental Health Survey (18). Each of these studies marks an important stage of development in Canadian psychiatric epidemiology, yet all share a common element: they were conducted in a specific region. Consequently, we have not to date had any national estimates of the prevalence of major psychiatric conditions in this country.
The Canadian Community Health Survey (CCHS) Cycle 1.2 remedies this, being a study of the entire country. As will be explained in this issue’s articles, it continues a long tradition of community surveys undertaken by Statistics Canada. The CCHS Cycle 1.1 yielded some data regarding the presence of psychological problems; however, its limitations in this regard prompted Cycle 1.2, whose major focus was on factors that predisposed people to or protected them from such problems. At the 2002 meeting of the Canadian Academy of Psychiatric Epidemiology (CAPE), representatives from Statistics Canada outlined the design of CCHS 1.2 and announced a joint Canadian Institutes of Health Research–Statistics Canada grant competition to analyze the data. The CAPE members decided to collaborate in their submissions rather than compete against each other for a limited number of grants, with very gratifying results in that a significant proportion of the grants were awarded to them. The entire 2004 CAPE meeting, which was held just prior to the annual Canadian Psychiatric Association meeting, was devoted to presentations of the results. The Journal’s Editorial Board agreed to devote one issue to those papers. To save space, a single article (see the paper by Gravel and Béland, 19) presents the methods used by all.
As will be indicated in the methods paper, the CCHS is funded as part of the Health Information Roadmap Initiative, a plan to modernize and standardize health information across the country (20). Statistics Canada, the Canadian Institute for Health Information, and Health Canada jointly support the series of projects that make up the Roadmap Initiative. CAPE members were part of the Expert Advisory Committee that also included consumer’s group representatives. Others contributed to the development of the training material, the piloting, and the support system for interviewers. In the end, the scope of the survey (for example, which mental disorders were covered) was determined by Statistics Canada.
This issue was originally intended to be an In Review section. However, because of the large number of excellent papers that were submitted, it was decided to devote an entire issue to papers presented at the CAPE meeting.
We—the guest editors, the presenters, and the CAPE executive—dedicate this issue to Dr Alec Leighton, one of the true pioneers of psychiatric epidemiology, not only in Canada but also in the world. He showed us the way as a researcher, as a teacher, and more importantly, as a symbol of humanity and decency, and we struggle to follow in his footsteps.
References
1. Klerman GL. Paradigm shifts in USA psychiatric epidemiology since World War II. Soc Psychiatry Psychiatr Epidemiol 1990;25:27–32.
2. Weissman MM. The epidemiology of psychiatric disorders: past, present, and future generations. Int J Methods Psychiatr Res 1995;5:69–78.
3. Jarvis E. Insanity and idiocy in Massachusetts: Report of the Commission on Lunacy. Cambridge (MA): Harvard University Press; 1971.
4. Srole L, Langner TS, Michael ST, Opler MK, Rennie TAC. Mental health in the community. New York: McGraw-Hill; 1962.
5. Leighton DC, Harding JS, Macklin DB, Hughes CC, Leighton AH. Psychiatric findings of the Stirling County Study. Am J Psychiatry 1963;119:1021–6.
6. Spitzer RL, Endicott J, Fleiss JL, Cohen J. The Psychiatric Status Schedule: a technique for evaluating psychopathology and impairment in role functioning. Arch Gen Psychiatry 1970;23:41–55.
7. Wing JK, Cooper JE, Sartorius N. The measurement and classification of psychiatric symptoms. London (UK): Cambridge University Press; 1974.
8. Endicott J, Spitzer RL. A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 1978;35:837–44.
9. Robins LN, Helzer JE, Crougham R, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry 1981;38:381–9.
10. Robins LN, Wing J, Wittchen H-U, Helzer JE, Babor TF, Burke J, and others. The Composite International Diagnostic Interview. Arch Gen Psychiatry 1988;45:1069–77.
11. Spitzer RL, Endicott J, Robins E. Research Diagnostic Criteria: rationale and reliability. Arch Gen Psychiatry 1978;35:773–82.
12. Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, and others. The NIMH Epidemiologic Catchment Area Program: historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 1984;41:934–41.
13. Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey: I. Lifetime prevalence, chronicity and recurrence. J Affect Disord 1993;29:85–96.
14. Beland Y. Canadian Community Health Survey: methodological overview. Health Rep 2002;13(3):9–14.
15. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand Suppl 1988;338:24–32.
16. Boyle MH, Offord DR, Hofmann HG, Catlin GP, Byles JA, Cadman DT, and others. Ontario Child Health Study. I. Methodology. Arch Gen Psychiatry 1987;44:826–31.
17. Boyle MH, Offord DR, Campbell D, Catlin G, Goering P, Lin E, and others. Mental health supplement to the Ontario Health Survey: methodology. Can J Psychiatry 1996;41:549–58.
18. 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.
19. Gravel R, Béland Y. The Canadian Community Health Survey: Mental Health and Well-Being. Can J Psychiatry 2005;50:573–9.
20. Canadian Institute for Health Information. Health Information Roadmap: beginning the journey. Canadian Institute for Health Information; 1999. Available: http://secure.cihi.ca/cihiweb/en/downloads/ profile_roadmap_e_eng-beg.pdf. Accessed 2005 Jul 13.
Author
1. Assistant Vice-President of Research and Director, Kunin-Lunenfield Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.
2. Research Scientist, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto, Ontario.
3. Professor, Department of Psychiatry, University of Montreal, Montreal, Quebec.
Address for correspondence: Dr D Streiner, Department of Psychiatry, University of Toronto, Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, ON M6A 2E1
e-mail: dstreiner@klaru-baycrest.on.ca
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