Progress toward achieving a common language in psychiatry. Results from the field trial of the clinical guidelines accompanying the WHO classification of mental and behavioral disorders in ICD-10.

In preparing for the 10th revision of the International Classification of Diseases (ICD-10), the Division of Mental Health of the World Health Organization organized an international field trial to help evaluate draft clinical descriptions and diagnostic guidelines that were produced to facilitate use of the chapter dealing with mental and behavioral disorders. These clinical guidelines were prepared in equivalent versions in most of the world's widely spoken languages. The field trial aimed to obtain data that would help in assessing whether the classification fits the diagnoses made in different countries, whether it is easy to use, and whether psychiatrists after a short period of familiarization with the classification can reach agreement about their diagnoses and classification. The field trial was carried out at 112 clinical centers in 39 countries by 711 clinicians who conducted 15,302 individual assessments. The trial included joint clinical assessments of patients and case history exercises. The results of the joint assessment part of the trial are reported here. Most clinicians reported that the draft document was easy to use and that the classification provided a good fit for the vast majority of the clinical conditions encountered. While interrater reliability was satisfactory for most categories, some (for example, those dealing with personality disorders) were somewhat difficult to use, and reliability of assignment for those was lower. The trial demonstrated that the ICD-10 chapter dealing with mental and behavioral disorders is on the whole suitable for general use. It provided valuable indications about changes needed for subsequent versions and demonstrated the feasibility of large-scale international research on classification and diagnosis in psychiatry.

Limitations of diagnostic criteria and assessment instruments for mental disorders. Implications for research and policy.

During the past 2 decades, psychiatric epidemiological studies have contributed a rapidly growing body of scientific knowledge on the scope and risk factors associated with mental disorders in communities. Technological advances in diagnostic criteria specificity and community case-identification interview methods, which made such progress feasible, now face new challenges. Standardized methods are needed to reduce apparent discrepancies in prevalence rates between similar population surveys and to differentiate clinically important disorders in need of treatment from less severe syndromes. Reports of some significant differences in mental disorder rates from 2 large community surveys conducted in the United States--the Epidemiologic Catchment Area study and the National Comorbidity Survey--provide the basis for examining the stability of methods in this field. We discuss the health policy implications of discrepant and/or high prevalence rates for determining treatment need in the context of managed care definitions of "medical necessity."

The ICD-10 clinical field trial for mental and behavioral disorders: results in Canada and the United States.

OBJECTIVE: To help evaluate the impact of proposed revisions to the chapter on mental and behavioral disorders for ICD-10, the World Health Organization (WHO) Division of Mental Health organized an international clinical field trial to evaluate draft clinical descriptions and diagnostic guidelines. The authors compare interrater diagnostic reliability results from this field trial for clinicians in Canada and the United States of American with those from all other clinicians worldwide, as well as with those from field trials conducted to evaluate drafts of DSM-III. METHOD: Two or more clinicians at each clinical center independently evaluated each patient, following a study protocol that allowed clinicians to list up to six diagnoses. In Canada and the United States, 96 clinicians completed 1,781 assessments among 491 patients, and elsewhere in the world 472 clinicians completed 7,495 assessments among 1,969 patients. RESULTS: Summary kappa coefficients at two-, three-, and four-character ICD-10 code levels were 0.76, 0.65, and 0.52, respectively, for Canadian and U.S. clinicians and 0.83, 0.75, and 0.62 for clinicians elsewhere. The mean number of diagnoses per assessment for Canadian and U.S. clinicians was 2.1; for clinicians elsewhere it was 1.7. More multiple coding of diagnoses for substance use disorders, mood (affective) disorders, and personality disorders by Canadian and U.S. clinicians accounted for much of the difference in diagnostic coding and in interrater reliability between them and clinicians elsewhere. CONCLUSIONS: Interrater diagnostic reliability in Canada and the United States was similar to that of clinicians worldwide and also to results from the DSM-III field tests. Use of more multiple coding of selected disorders by Canadian and U.S. clinicians may reflect the influence of DSM-III and DSM-III-R, which encourage multiple diagnostic entries and the use of separate multiaxial coding for personality disorders, and may have reduced interrater concurrence for some categories. Further, collaborative development of ICD-10 with DSM-IV has aligned these two systems more closely.

Drinking habits and death. The Yugoslavia cardiovascular disease study.

In a prospective study of more than 10000 Yugoslav men it was found that consumption of alcoholic beverages was inversely related to non-sudden death from coronary heart disease (CHD) and positively related to death from trauma. The consequence was an apparently U-shaped relation between alcohol consumption and death, the lowest mortality being among moderate drinkers. Excess mortality from trauma was evident only among men under 55 and only for those who reported at entry to the study that they had been drunk during the preceding week. Alcohol consumption as reported at entry was unrelated to subsequent mortality from liver cirrhosis or any form of cancer. An enlarged liver, however, was associated with higher death rates for liver cirrhosis. This raises the possibility that some of the men were heavy drinkers preceding their entry to the study but were no longer drinking heavily at the time of entry. Enlarged liver, however, was also related to hypertension and to chronic obstructive pulmonary disease and thus was not a specific indicator of alcohol abuse in this population. Recent drunkenness but not frequency of drinking was related to death from trauma and liver cirrhosis and to sudden CHD death. In short, both the pattern of drinking and the usual level of alcohol consumption appear to be related to mortality in this population.

International use and attitudes toward DSM-III and DSM-III-R: growing consensus in psychiatric classification.

A survey of the uses and attitudes of 146 mental health professionals, primarily psychiatrists and psychologists, in 42 countries (not including the United States) toward the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and its revision (DSM-III-R; American Psychiatric Association, 1980,1987) is reported. The results revealed wide-spread endorsement of the multiaxial system, theoretical neutrality, descriptive symptom criteria forming discrete categories, and the placement of personality disorders on a separate axis. We report that the DSM-III and DSM-III-R are more widely used around the world than the International Classification of Diseases for teaching, research, and clinical practice. Opinions about various dimensions of the DSM's usefulness and shortcomings are presented.

The influence of alcohol abuse as a hidden contributor to mortality.

Although only about 2-3 percent of annual deaths are attributed to one of the four underlying causes linked to chronic alcohol use, research results suggest that the impact of alcohol is much greater. The recent issue of mortality multiple cause of death tapes from National Center for Health Statistics permit exploration of associations of chronic alcohol abuse with conditions coded as underlying cause of death and provide leads for case-finding. Data analysis is reported from certificates of resident deaths in the United States in 1978. There are 12 groups of underlying causes for which the percentage of pairings with chronic alcohol abuse ranges from 4-16 percent of the number of deaths from the underlying cause. Age, sex, and metropolitan status of residence are associated with a listing of chronic alcohol abuse among decedents of liver cancer, varicose veins, symptomatic heart disease, septicemia, and respiratory system disease. Planners concerned with secondary prevention can use these clues provided by logistic regression modelling as an aid in case-finding.

Alcohol problems among employed men and women in metropolitan Detroit.

A survey of employed adults in metropolitan Detroit showed that more men than women had alcohol problems but this was largely attributable to the higher percentage of alcohol-dependent drinkers among men. There was little difference between the percentages of men and women who could be identified as nondependent problem drinkers.

Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders.

BACKGROUND: The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity. METHOD: Cross-sectional and prospective data on 20,291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period. RESULTS: Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder. CONCLUSIONS: Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.

Drinking habits and other characteristics: the Yugoslavia Cardiovascular Disease Study.

In two large general populations of Yugoslav men from Tuzia, Bosnia, and Remetinec, Croatia, examined in 1964-1965, it was found that a greater alcohol consumption was accompanied by higher blood pressures, higher pulse rates, and higher concentrations of serum cholesterol and hematocrit. A greater consumption was also associated with an enlarged liver, as well as a higher prevalence rate of chronic bronchitis and thrombophlebitis. All these were statistically significant even after allowing for differences in cigarette smoking and demographic characteristics. Pulse rate, liver size, and varices appear to be specifically associated with a history of episodes of drunkenness. There were significant differences in drinking habits by place of residence, religious background, years of schooling, and kind of work. These were allowed for in evaluating the relationship of drinking to other characteristics. Two anomalous findings were low prevalence rates for diabetes and gastritis among those drinking most frequently.

How Americans say they drink: preliminary data from two recent national surveys.

Data from two recent National Center for Health Statistics (NCHS) surveys which included alcohol consumption questions are described. These surveys are the Health and Nutrition Examination Survey (HANES I), providing alcohol consumption, dietary recall, health and demographic data for over 20,000 respondents; and the Health Habits Section of the 1977 Health Interview Survey (HIS) which provides responses of 23,000 people on drinking behavior and health factors such as smoking, physical disabilities, and dietary habits. Drinking data from these surveys are limited but of sufficient accuracy to be useful for cross-classification of drinking with health, socio-economic and demographic variables. Drinking patterns correlate reasonably well with those reported in other national surveys. Selected findings show that patterns of drinking and dietary intake are similar at national and regional levels, with the South remaining the region lowest in alcohol consumption levels. Surveys consistently under-report alcohol quantities expected from sales in all regions; potential reasons for this are discussed. Highest consumption is reported by males (3 to 4 times that of females), those with European national origins, those who are working or in school (college) rather than those who are retired or keeping house, and those between 25 and 64 years old. Beer remains the beverage of choice, particularly among those who are the heaviest drinkers. The potential for future analyses of drinking behavior and its health implications is explored, and areas for further investigation are suggested. Data preparations have been completed so that information on alcohol consumption can be more readily related to medical history, medical examination, laboratory findings, disability, and health care data in these surveys.

Drinking habits and coronary heart disease: the Yugoslavia cardiovascular disease study.

In a prospective study of more than 10,000 Yugoslav men residing in Bosnia and Croatia, who were first examined in 1964--1965, consumption of alcoholic beverages was related inversely to the subsequent appearance of coronary heart disease clinically manifest as myocardial infarction or nonsudden coronary heart disease death. Consumption of alcoholic beverages was not so related to sudden cardiac death. Men who drank most frequently had half the subsequent incidence of overall coronary heart disease as men who seldom or never drank. This finding was true for urban residents only. Serum cholesterol and Quetelet index were also related to coronary heart disease in urban areas but not in rural areas. The inverse relation of alcohol consumption to coronary heart disease incidence was statistically significant even after taking into account differences in blood pressure, serum cholesterol levels, cigarette smoking and other variables. The apparent absence of protection against sudden death may be due to chance or it may reflect the deleterious effects of high alcohol consumption on the myocardial cells and increased vulnerability to lethal arrhythmias in an especially lean population. There is, in fact, a specific association of recent drunkenness with sudden death in this population. Conceivably, the acute effect of heavy drinking may be a dominant factor in the incidence of sudden death for this population.