4327.0 - National Survey of Mental Health and Wellbeing: Users' Guide, 2007
ARCHIVED ISSUE Released at 11:30 AM (CANBERRA TIME) 11/02/2009
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3. MENTAL DISORDERS AND CONDITIONS
This chapter also contains information on:
A brief comparison of differences between the diagnostic assessment criteria used for the 1997 and 2007 surveys is provided in Chapter 4 for both classifications (DSM-IV and ICD-10). The comparisons focus on the differences in assessment criteria, rather than on minor question wording or sequencing changes, as these are thought to have negligible impact on comparability. More information on measuring mental health, including details on the World Mental Health Survey Initiative version of the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI), version 3.0 (WMH-CIDI 3.0), is provided in Chapter 2. SCREENER A screener was introduced to the WMH-CIDI 3.0 to try to alleviate the effects of learned responses. The module included a series of introductory questions about the respondent's general health, followed by diagnostic screening questions for the primary disorders assessed in the survey, eg depressive episode. The screener questions are designed to determine if a person is likely to have symptoms of particular disorders. The use of screener questions has been shown to increase the accuracy of diagnostic assessments, by reducing the effects of learned responses due to respondent fatigue. Other disorders, such as Obsessive-Compulsive Disorder (OCD), were screened at the beginning of the individual module. The introductory questions to the screener are part of a standard ABS module, which measures the respondents' perceptions of their overall health and life in general. These questions do not take into account specific illnesses or problems the person may have, only their perceived level of health or life in general. The remaining questions in this module are diagnostic screener questions, which are linked to later modules in the survey instrument. This includes a number of 'second chance' questions, where the respondent is given more than one chance to endorse symptoms, which would 'screen' them into a particular diagnostic module. People were only asked a 'second chance' question if they said 'No' to the first question. For example, 'Have you ever in your life had an attack of fear or panic when all of a sudden you felt very frightened, anxious or uneasy?' If this question was not endorsed, then the following 'second chance' question was asked - 'Have you ever had an attack when all of a sudden:
MENTAL DISORDERS The survey provides WMH-CIDI 3.0 diagnoses for selected mental disorders according to both the ICD-10 and DSM-IV classifications. Variations in the diagnostic assessment criteria for each classification may therefore give differing estimates for the overall prevalence of mental disorder, as well as for specific disorders. The survey included mental disorders that:
In 2007, the prevalence of mental disorders is based on the diagnosis of a lifetime disorder, with or without symptoms in the 12 months prior to interview. In comparison, the 1997 survey considers only symptoms during the 12 months prior to interview for diagnosis. Probe questions The CIDI instrument probes respondents through a series of questions about symptoms, problems or experiences in order to establish whether these were clinically significant and also whether they were due to medication, drugs, alcohol or a physical illness or injury. The questions on clinical significance assessed whether the symptoms were sufficiently severe for the person to seek professional help, or whether the symptoms interfered with his or her life or activities excessively. The symptoms were considered below clinical significance if the person:
The probe questions excluded symptoms due to the effects of psychoactive substance use (medication, drugs or alcohol), or physical illness or injury. Questions sought to establish whether symptoms were always the result of the person:
If either of these explanations, or some combination of the two, accounted for all of the occurrences of the symptoms, then these symptoms did not count towards a diagnosis of mental disorder. ICD-10 diagnoses of mental disorders The following ICD-10 diagnoses were assessed by the survey: Anxiety disorders
Affective disorders
Substance use disorders
DSM-IV diagnoses of mental disorders The following DSM-IV diagnoses were assessed by the survey: Anxiety disorders
Affective disorders
Substance use disorders
Hierarchy rules The classification system for some of the mental disorders contain diagnostic exclusion rules so that a person, despite having symptoms that meet diagnostic assessment criteria, will not meet criteria for particular disorders because the symptoms are believed to be accounted for by the presence of another disorder. In these cases, one disorder takes precedence over another. These exclusion rules are built into the diagnostic algorithms. The WMH-CIDI 3.0 includes two versions of diagnoses in the algorithms for a number of the mental disorders, based on:
An example of a disorder specified with and without hierarchy is the Harmful Use of alcohol. The ICD-10 states that in order to meet the diagnostic assessment criteria for Harmful Use, criteria cannot be met for Dependence on the same substance during the same time period. The ‘with hierarchy’ version of the Harmful Use of alcohol will therefore exclude cases where Dependence on alcohol has been established for the same time period. The ‘without hierarchy’ version includes all cases of alcohol Harmful Use regardless of coexisting alcohol Dependence. Note that a person can meet criteria for Dependence on alcohol and the hierarchical version of Alcohol Harmful Use if there is no overlap in time between the two disorders. The survey publication, National Survey of Mental Health and Wellbeing: Summary of Results, 2007 (cat. no. 4326.0) presents the ICD-10 prevalence rates with the hierarchy rules applied, except for the comorbidity data, which are presented without hierarchy. The mental disorders specified with and without hierarchy are outlined later in this chapter and an example of the differences in prevalence rates with and without hierarchy rules applied is provided in the following table.
Comorbidity Comorbidity refers to the occurrence of more than one disorder at the same time. Comorbidity may refer to the co-occurrence of mental disorders and the co-occurrence of mental disorders and physical conditions. The existence of some conditions may predispose individuals to others. For example, severe social phobia may contribute to depression and alcohol dependence. Further, the presence of mental and/or physical conditions in combination is likely to compound the difficulties people face. The 2007 SMHWB enables analysis of comorbidity, both in terms of the number of disorders, and the combinations of different types of comorbidity. Onset, recency and persistence All of the disorder-specific sections assess the onset and recency of symptoms, as well as the persistence of episodes. Onset The onset of symptoms was obtained by asking the respondent their exact age the very first time they had a particular symptom or episode. Recency The recency of symptoms was determined by asking the respondent their exact age the last time they had a particular symptom or episode. Questions about onset (first time) and recency (last time) were asked for each group of symptoms that may have corresponded to a diagnosis of mental disorder. Therefore, if a person had experienced symptoms or an episode in the 12 months prior to interview they were asked how recently this occurred. With the exception of dysthymia, responses were categorised as:
Persistence Persistence relates to the length of time that a symptom or episode was present. Depending on the mental disorder being assessed, a person may have been asked to provide their age in years for:
From the information provided, persistence was calculated within the diagnostic algorithms and the duration output in years. The persistence questions varied across mental disorders, recognising that they may be:
Note that in the 1997 survey, persistence was referred to as duration. ICD-10 DIAGNOSTIC ASSESSMENT CRITERIA Introduction The following information provides descriptions of the WMH-CIDI 3.0 diagnostic assessment criteria according to the WHO International Classification of Diseases, Tenth Revision (ICD-10). Note that not all exclusions specified in the ICD-10 were able to be addressed in the survey. Therefore, some of the descriptions differ from the ICD-10. ICD-10 Anxiety disorders Anxiety disorders generally involve feelings of tension, distress or nervousness. A person may avoid, or endure with dread, situations which cause these types of feelings. The disorders within this group assessed in this survey are:
Panic Disorder A panic attack is a discrete episode of intense fear or discomfort that starts abruptly and reaches a peak within 10 minutes. At least four symptoms must be present from the list below, one of which must be from the first four:
The essential feature of Panic Disorder is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances (ie do not occur in the presence of a phobia, or in situations of danger) and are therefore unpredictable. Agoraphobia The disorder is characterised by marked and consistently manifest fear in, or avoidance of, at least two of the following situations:
At least two of the following anxiety symptoms must have been present together with the feared situation and one of these symptoms must be from the first four listed:
The person also experiences significant emotional distress due to the avoidance or the anxiety symptoms and recognises that these are excessive or unreasonable. Social Phobia The disorder is characterised by fear and/or avoidance of one or more social or performance situations such as:
The presence of Social Phobia is also characterised by:
Generalised Anxiety Disorder (GAD) The disorder is characterised by a period of at least six months with tension, worry and apprehension about everyday events and problems. The disorder is not due to a physical disorder or substance use. At least four of the following symptoms must be present, with at least one of the first four:
Hierarchy rules have been applied to GAD. To meet criteria for the 'with hierarchy' version:
The original exclusion rules from the ICD-10 also consider the presence of other phobic disorders and hypochondriacal disorder. As the 2007 SMHWB did not collect information for Specific Phobia or Hypochondriacal Disorder, the GAD prevalence may include some people with these disorders. Obsessive-Compulsive Disorder (OCD) Either obsessions or compulsions (or both) are present on most days for at least two weeks. Obsessions (thoughts, ideas or images) and compulsions (acts) share the following features, all of which must be present:
Post-Traumatic Stress Disorder (PTSD) The disorder is characterised by symptoms experienced within six months of exposure to an extremely traumatic event which would be likely to cause pervasive distress in almost anyone. In order to be assessed for this disorder, a person had to report that they had experienced at least one of the following traumatic events:
People were asked to determine which event was their worst traumatic event. To meet the criteria for this disorder, a person must have reported all of the following reactions:
ICD-10 Affective disorders Affective disorders involve mood disturbance, or change in affect. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations. Disorders within this group include:
Depressive Episode A Depressive Episode lasts for at least two weeks and is characterised by the presence of a number of the following symptoms:
The survey collected information to differentiate between three different types of Depressive Episode, based on the number of symptoms a person experienced:
Hierarchy rules have been applied to all of the Depressive Episodes. To meet criteria for the 'with hierarchy' versions, a person cannot have met criteria for either Hypomanic or Manic episodes in their lifetime. The three types of Depressive Episode collected by the survey are also mutually exclusive. A person cannot be diagnosed with Moderate Depressive Episode if the criteria for a Severe Depressive Episode have already been met and a diagnosis of a Mild Depressive Episode is considered only when the other two types of depression have been excluded. This criteria is applied regardless of whether the 'with hierarchy' or 'without hierarchy' version of the disorder is used. Dysthymia A disorder characterised by at least two years of constant (or constantly recurring) chronic depressed mood, where intervening periods of normal mood rarely last for longer than a few weeks. During some of the periods of depression, at least three of the following are present:
Hierarchy rules have been applied to Dysthymia. To meet criteria for the 'with hierarchy' version:
Hypomania Hypomania is characterised by elevated or irritable mood to a degree that is abnormal for the person concerned and sustained for at least four consecutive days. Symptoms lead to some interference with daily living but to a lesser degree than Mania. At least three of the following symptoms must be present:
Hierarchy rules have been applied to Hypomania. To meet criteria for the 'with hierarchy' version, the person cannot have met criteria for an episode of Mania in their lifetime. The original exclusion rules also consider the presence of any Depressive Episodes, Cyclothymia and Anorexia Nervosa. As the 2007 SMHWB did not collect information for Cyclothymia or Anorexia Nervosa (and the presence of Depressive Episodes was not assessed in the diagnostic algorithm), Hypomania may include some persons with these disorders. Mania Mania is characterised by a person's mood being elevated, expansive or irritable and definitely abnormal for their personality. The episode lasts for at least seven days (unless the episode is severe enough to require hospitalisation), causes severe interference with personal functioning, is not directly caused by substance use or a physical condition, and is characterised by at least three of the following (four if the mood is merely irritable):
Bipolar Affective Disorder The disorder is characterised by episodes of Mania or Hypomania either alone or in conjunction with Depressive Episodes. For this survey, a person met diagnosis of Bipolar Affective Disorder if they met the criteria for Mania or Hypomania and experienced at least two episodes of mood disturbance, consisting of either:
ICD-10 Substance Use disorders The survey collected information on the Harmful Use and Dependence on alcohol and other substances. Detailed questions about alcohol use were only asked if the person had at least 12 standard alcoholic drinks in a 12-month period. Standard drink A standard drink contains 12.5ml of alcohol. the serving size determines the number of standard drinks per serve, as shown in the following table:
Detailed questions about drug abuse and dependence were only asked if a person had:
Alcohol Harmful Use A diagnosis occurs where there is clear evidence that the use of alcohol was responsible for (or substantially contributed to):
The nature of the harm should be clearly identifiable by including at least one of the following:
Hierarchy rules have been applied to Alcohol Harmful Use. To meet criteria for the 'with hierarchy' version, a person cannot have met a diagnosis of Alcohol Dependence during the same time period (ie the duration of the two disorders must not overlap). Alcohol Dependence Syndrome A maladaptive pattern of behaviour in which the use of alcohol takes on a much higher priority for a person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to consume alcohol despite significant alcohol-related problems. A diagnosis was achieved if three or more of the following occurred within the same year:
Drug Use Disorders The Harmful Use and Dependence on drugs was only assessed if a person had used an illicit drug or misused prescription medication more than five times in their lifetime. The misuse of prescription medication includes:
A general assessment was made for Harmful Use and Dependence on any drugs. The Harmful Use and Dependence on four specific categories of drugs were also assessed. The categories of drugs were:
Other Substance Harmful Use This survey collected information on:
A diagnosis occurs where there is clear evidence that the use of opioids/cannabinoids/sedatives/stimulants were responsible for (or substantially contributed to):
The nature of the harm should be clearly identifiable by including at least one of the following:
Hierarchy rules have been applied to Other Substance Harmful Use. To meet criteria for the 'with hierarchy' versions, a person cannot have met a diagnosis of Dependence on the same substance during the same time period (ie the duration of the two disorders must not overlap). Other Substance Dependence Syndrome This survey collected information on:
Opioid/Cannabinoid/Sedative/Stimulant Dependence Syndrome is a maladaptive pattern of substance use in which the use of the substance takes on a much higher priority for a person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to take the substance despite significant substance-related problems. A diagnosis was achieved if three or more of the following occurred for the same substance in the same 12-month period:
DSM-IV DIAGNOSTIC ASSESSMENT CRITERIA Introduction The following information provides descriptions of the WMH-CIDI 3.0 diagnostic assessment criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Note that not all exclusions specified in the DSM-IV were able to be addressed in the survey. Therefore, some of the descriptions outlined differ from the DSM-IV. Exclusion criteria Symptoms are not due to the direct physiological effects of a substance or general medical condition. DSM-IV Anxiety disorders Anxiety disorders generally involve feelings of tension, distress or nervousness. A person may avoid, or endure with dread, situations which cause these types of feelings. The disorders within this group assessed in this survey are:
Panic Disorder The essential feature of this disorder is recurrent panic (anxiety) attacks that occur suddenly and unpredictably. At least one of the attacks has been followed by one month or more of at least one of the following:
Panic Disorder with/without Agoraphobia A person may have met criteria for Panic Disorder with or without the presence of Agoraphobia. Panic Attack A period of intense fear or discomfort which begins suddenly and reaches a peak within ten minutes. At least four of the following symptoms are present:
Agoraphobia The disorder is characterised by anxiety about being in situations from which escape might be difficult (or embarrassing) or in which help may not be available if the person has a panic attack. Such situations include:
The person avoids the situations, endures them with distress or requires the presence of a companion. Agoraphobia without Panic Disorder The symptoms of Agoraphobia relate to a fear of developing panic-like symptoms, but the person has never met the criteria for Panic Disorder. Social Phobia The disorder is characterised by a marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or to possible scrutiny by others. The person fears that they will act in a way (or show anxiety symptoms) that will be embarrassing or humiliating. Exposure to the feared situation almost always provokes anxiety which may take the form of a panic attack. The feared situations are avoided, or endured with distress and the person recognises that the fear is excessive or unreasonable. The disorder is accompanied by clinically significant distress and interference with normal routine and functioning. For people who were aged less than 18 years when the symptoms last occurred, the duration of the symptoms must have been at least six months. For people who were aged at least 18 years when the symptoms last occurred, the duration of the symptoms must have been more than one year. Generalised Anxiety Disorder (GAD) The disorder is characterised by excessive anxiety and worry about a number of events or activities, occurring more days than not for at least six months. Three or more of the following symptoms are present (with at least some present for more days than not for the six months prior to interview):
The person finds it difficult to control the worry, and it causes clinically significant distress or impairment in social, occupational or other important areas of functioning. A person is excluded from diagnosis if the GAD is associated with one or more of the following self-reported conditions:
Hierarchy rules have been applied to GAD. To meet criteria for the 'with hierarchy' version, the symptoms/disturbance cannot have occurred exclusively during a mood disorder (Major or Minor Depressive Disorder, Dysthymia or Mania). Obsessive-Compulsive Disorder (OCD) The disorder is characterised by either obsessions, compulsions or a combination of both. Obsessions are defined by the following:
Compulsions are defined by the following:
The disorder is also characterised by the obsessions or compulsions:
Additionally, the person realises that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions cannot occur exclusively within episodes of depression. In this case, depression was based on the endorsement of questions about being sad or depressed when the symptoms of OCD occurred. Therefore, depression was self-reported and not verified medically or through a CIDI diagnosis. Post-Traumatic Stress Disorder (PTSD) The disorder is characterised by symptoms lasting more than one month following exposure to an extremely traumatic event in which the person experienced or witnessed:
The person's response to the event involved intense fear, helplessness or horror. The traumatic event is persistently re-experienced in one or more of the following ways:
In addition, the person exhibits avoidance of things associated with the event evidenced by three or more of the following:
Further, two or more of the following symptoms of increased arousal are present:
The disturbance causes clinically significant distress or impairment in social, occupational and other important areas of functioning. DSM-IV Affective disorders Affective disorders involve mood disturbance, or change in affect. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations. Disorders within this group include:
Major Depressive Episode This disorder is characterised by the presence of five or more symptoms during the same two week period, with at least one of the symptoms from the first two on the list:
These symptoms must represent a change from previous functioning, and are not better accounted for by bereavement. If the depressive episode is associated with bereavement then the episode must be longer than two months duration. In addition, the episode must be accompanied by clinically significant distress or impairment in social, occupational or other important areas of functioning. The survey also collected information on: Major and Minor Depressive Disorders In order to be diagnosed with Major Depressive Disorder a person must have met criteria for a single Major Depressive Episode. Hierarchy rules have been applied to Major Depressive Disorder. For the 'with hierarchy' version, a diagnosis can only be made if a person has never met criteria for a Hypomanic or Manic Episode. Minor Depressive Disorder is diagnosed if a person has at least two (but less than five) symptoms of a Major Depressive Episode. Hierarchy rules have been applied to Minor Depressive Disorder. For the 'with hierarchy' version, a diagnosis can only be made if a person has never:
Recurrent Brief Depression This disorder is characterised by the presence of symptoms lasting at least two days, but less than two weeks. The symptoms occur at least once a month for 12 consecutive months and are not associated with the menstrual cycle. The symptoms cause significant distress or impairment in social, occupational or other areas of functioning. At least five of the following symptoms must be present and at least one of the symptoms should be from the first two on the list:
The symptoms are not better accounted for by bereavement, or if the symptoms are associated with bereavement they have persisted for longer than two months. Hierarchy rules have been applied to Recurrent Brief Depression. For the 'with hierarchy' version, a diagnosis can only be made if a person has never:
As this survey did not collect information on Mixed Episode or Cyclothymic Disorder, Recurrent Brief Depression may include some people with these disorders. Dysthymic Disorder The disorder is characterised by a chronically depressed mood, that occurs for most of the day and on more days than not, for at least two years. There cannot have been a break of two months or more. Additionally, at least two of the following symptoms are present:
The episode must be accompanied by significant clinical distress or impairment in social, occupational or other important areas of functioning. Hierarchy rules have been applied to Dysthymia. For the 'with hierarchy' version, a diagnosis can only be made if the initial two-year period of symptoms is free of Major Depressive Episodes and the person has never had a Hypomanic or Manic episode. Hypomanic Episode An episode is characterised by an abnormally elevated, expansive or irritable mood lasting at least four days. Three or more of the following symptoms (four if the mood is only irritable) are present:
While the episode is associated with an unequivocal change in functioning, that is uncharacteristic of the person when not symptomatic, it is not severe enough to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation. There are no psychotic features. Manic Episode An episode is characterised by an abnormally elevated, expansive or irritable mood lasting at least seven days (or any duration if hospitalisation is required). Three or more of the following symptoms (four if the mood is only irritable) are present:
The episode causes marked impairment in:
The episode may also necessitate hospitalisation to prevent harm to self or others. Psychotic features may be present. Bipolar I and II Disorders Bipolar I and Bipolar II Disorders are mutually exclusive. Bipolar I Disorder This disorder is characterised by the occurrence of one or more Manic Episodes. Often the person has also had one or more Major Depressive Episodes. Bipolar II Disorder This disorder is characterised by the presence of either:
DSM-IV Substance Use disorders The survey collected information on the abuse and dependence on alcohol and other substances. Detailed questions about alcohol use were only asked if the person had at least 12 standard alcoholic drinks in a 12-month period. A standard drink contains 12.5ml of alcohol. the serving size determines the number of standard drinks per serve. See 'Standard drink' earlier in this chapter. Detailed questions about drug abuse and dependence were only asked if a person had:
The misuse of prescription medication includes:
Drugs were categorised by four main types:
Alcohol Abuse A maladaptive pattern of alcohol use leading to clinically significant impairment or distress. It is evident that alcohol is responsible for or substantially contributes to physical or psychological harm, or dysfunctional behaviour. A diagnosis was achieved if one or more of the following problems occurred in the same 12-month period:
Hierarchy rules have been applied to Alcohol Abuse. To meet criteria for the 'with hierarchy' version, a person cannot have met criteria for Alcohol Dependence. Alcohol Dependence A maladaptive pattern of behaviour in which the use of alcohol takes on a much higher priority for the person that other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to consume alcohol despite significant alcohol-related problems. A diagnosis was achieved if three or more of the following problems occurred in the same 12-month period:
Drug Use Disorders As outlined earlier, Substance Abuse and Dependence were only assessed where a person had:
Substance Abuse The survey collected information on:
Substance Abuse is a maladaptive pattern of drug use leading to clinically significant impairment or distress. It is evident that the use of opioids/cannabinoids/sedatives/stimulants were responsible for or substantially contributed to physical or psychological harm, or dysfunctional behaviour. A diagnosis was achieved if one or more of the following problems occurred in the same 12-month period:
Hierarchy rules have been applied to Substance Abuse. To meet criteria for the 'with hierarchy' version, a person cannot have met a diagnosis of Dependence on the same type of substance during the same time period. Substance Dependence The survey collected information on:
Substance Dependence is a maladaptive pattern of drug use in which the use of drugs takes on a much higher priority for the person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to take the substance despite significant substance-related problems. A diagnosis was achieved if three or more of the following occurred for the same substance in the same 12-month period:
COMPARISON WITH THE 1997 SURVEY A brief overview of the differences in the diagnostic assessment criteria used for the 1997 and 2007 surveys is provided in Chapter 4. The comparisons are segmented by the classification used for diagnosis (ICD-10 or DSM-IV), the major groups of mental disorders (Anxiety, Affective and Substance Use) and selected mental disorders. As the emphasis is on comparing differences between the two surveys, not all assessment criteria are mentioned for each disorder. A summary of the full diagnostic assessment criteria used for the 2007 survey is provided earlier in this chapter. Document Selection These documents will be presented in a new window.
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