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Theoretical Perspectives on Mental Health and Illness: Introduction to Part I
Jerome C. Wakefield, University Professor, Silver School of Social Work and Department of Psychiatry, School of Medicine, New York University,
Mark F. Schmitz, Associate Professor, School of Social Administration, Temple University, Philadelphia, PA
This chapter examines the assessment and measurement of mental disorders. Researchers must distinguish between clinical prevalence (people who are treated for mental disorder) and true prevalence (the actual rate of disorder in a community, including those not in treatment). The measurement of mental illness must be conceptually valid; that is, there must be criteria that successfully distinguish cases of disorder from cases of non-disorder. In the past, researchers relied upon general symptom checklists, which identify a threshold above which an individual is considered disordered, but without specifying a particular disorder. An alternative to checklists is provided by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) of mental disorders, which provides sets of diagnostic criteria for specific disorders. The assumption behind the DSM is that mental disorders result from internal psychological dysfunctions (i.e., failures of proper functioning of mental processes), a presumption that Wakefield and Schmitz accept but demonstrate is often violated by the DSM's own criteria for mental disorder. Their critique of the DSM's approach to measurement is illustrated with several DSM diagnoses. In addition to thoroughly discussing the conceptual basis of the DSM, Wakefield and Schmitz provide examples of the attempts to use DSM-derived criteria to measure prevalence of mental disorder in the community. These examples demonstrate the recurrent problems with creating conceptually valid measures for use in psychiatric epidemiology. It is unclear whether these problems can be overcome or circumvented with methodological innovations. The student should consider why it is so difficult to determine who is mentally disordered, and to distinguish mental disorder from intense normal distress. Is a conceptually valid resolution of these problems possible?
How many people in the United States suffer from mental disorder in general and from each specific mental disorder, and what characteristics are correlated with each disorder? The answers to such questions are important in formulating mental health policy, in evaluating theories of the causes of disorder, in planning efficient distribution of mental health care, and in justifying funding for mental health services and research. Thus, there have long been efforts to measure the rate, or prevalence, of mental disorder both in the population as a whole and in various segments of the population. Psychiatric epidemiology, the discipline that pursues such studies, is logically part of medical epidemiology, the study of the occurrence and correlates of medical disorders in various populations.
Two tuffs in the Lower Cretaceous Agrio Formation, Neuquén Basin, provided U–Pb zircon radioisotopic ages of 129.09±0.16 Ma and 127.42±0.15 Ma. Both horizons are well constrained biostratigraphically by ammonites and nannofossils and can be correlated with the ‘standard’ sequence of the Mediterranean Province. The lower horizon is very close to the base of the Upper Hauterivian and the upper horizon to the Hauterivian/Barremian boundary, indicating that the former lies at c. 129.5 Ma and the latter at c. 127 Ma. These new radioisotopic ages fill a gap of over 8 million years in the numerical calibration of the current global Early Cretaceous geological time scale.
This chapter examines the assessment and measurement of mental disorders. It explores the special problems that have arisen in epidemiologists' attempts to transfer diagnostic criteria from the domain of clinical evaluation to the much different epidemiological arena in which disorder is measured in the general population by survey. Some early psychiatric epidemiological studies were based on the assumption that clinical prevalence could be used to validly infer the community population's true prevalence. The most notable attempt in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to make general progress on the false positives problem has been the development of a clinical significance (CS) criterion for use in evaluating mental disorder. The chapter also presents an example of a recent attempt to use DSM derived criteria in an epidemiological study to measure the prevalence of a particular mental disorder, namely, major depressive disorder (MDD).
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