Primary Health Care and Psychiatric Epidemiology

Brian Cooper, Robin Eastwood, Brian Cooper, Robin Eastwood

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138332065
• eBook ISBN: 9780429823213
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In the years prior to publication, primary health care had been gaining in significance as a setting both for research on mental illness in the general population and for the development of new preventive approaches in this field. The growing need for research had received impetus from the escalating costs of hospital-based health care, the re-structuring of health services in a number of countries, with an increased emphasis on community care and prevention, and the World Health Organization's 'Health for All' campaign, in response to which a growing number of national planning documents had been published. These developments had already stimulated a new interest in the scope for epidemiological and evaluative investigations based on general medical practice.

This book, originally published in 1992, consists of selected contributions to the first international scientific meeting on this topic, held in Toronto in 1989. It is made up of five sections, dealing respectively with: the growth and development of a new research field; findings of psychiatric surveys in general practice in a number of different countries; specialist and generalist medical care for mental illness – issues of selection and referral; and specialist aspects of late-life mental disorders encountered in such research. The inclusion of reports from groups of workers in the USA, the UK, the Netherlands, Germany, Spain, Italy, Finland, Canada, Australia and other countries testifies to the rapid spread of interest in these questions.

With the exception of the first two chapters, which sketch the background of public-health and general-practice epidemiology, all the contributions are focused on general practice as a field laboratory for study of the occurrence, distribution, diagnostic composition and risk factors of psychiatric illness in unselected populations, and present data, largely unpublished, from the authors' own projects. These findings confirm the importance of research in general practice as a major growing-point of social psychiatry and provide guidelines for further progress in the years ahead.

This book will still be an invaluable source of reference to all psychiatrists, psychologists, general practitioners and health care professionals concerned with mental disorders in the wider community.

Part I

Psychiatric epidemiology and general practice: the development of a research field

Chapter 1

The science of epidemiology

Empirical data gathering, public-health action, or both?

Leon Eisenberg

The application of the methods of psychiatric epidemiology to the study of mental health problems in primary health care is a relatively recent development (Shepherd 1990). That short history made it possible for the founder of this field of investigation, Professor Michael Shepherd, to be a participant in the World Psychiatric Association Symposium reported in this volume, a symposium convened just thirty years after the publication of his first report on the topic (Shepherd et al. 1959). Few recognized its importance at the time; fewer still took it up. For the next several decades, psychiatric epidemiology in primary care was broadened and deepened primarily by Michael Shepherd and the Maudsley psychiatrists he helped to train and equip to explore this terrain: David Goldberg, John Cooper, Anthony Clare and Anthony Mann in Britain, Brian Cooper in Germany, Robin Eastwood in Canada, Michele Tansella in Italy, Assen Jablensky in Bulgaria and Norman Sartorius at the World Health Organization.

Despite some missionary work in the States by David Goldberg, recognition of the size of the mental health burden in general medical practice did not begin to take hold in North America until the paper by Regier and co-workers (1978) on what they called the de facto US mental health services system. Their account made it evident that, in the USA, just as in the UK and in the developing world (Harding et al. 1980), primary-care physicians are the principal, and often the only, resource for patients who are psychologically disturbed. I use the phrase ‘did not begin to take hold’ advisedly. Psychiatric educators and mental health policy makers in the USA continue to pay lip-service to the implications of the epidemiologic data for modifications in the organization of service delivery and in the education of generalists. The record in the UK, if still far short of the mark, is considerably better in this regard, much of that progress being due to systematic data produced by psychiatrists trained at the Maudsley.

How bizarre, now that Professor Shepherd has become Emeritus, for his General Practice Unit to have been phased out as part of the savage Thatcher retrenchment on research expenditures! In the UK, as in the USA, Tory governments have learned that epidemiologic surveillance, because it reveals gaps in service delivery, generates public pressure for additional care and, hence, additional costs (Eisenberg 1989a). With ‘prevention’ the new password in health policy, it is no small irony that governments are opting to prevent research; that is, the systematic gathering and release of information on the operation of the health services. The operative principle seems to be that what the public doesn’t know won’t hurt it (‘it’, in this instance, being the government!).

What makes the study of psychiatric disorders in primary care so crucial is that it asks questions which matter for patients, for front-line doctors and for health policy makers. How great is the burden of psychological ill health in the case load of primary care physicians? To what extent is that burden recognized by either patients or doctors? Does its identification lead to useful interventions? Can the diagnostic and therapeutic performance of generalists be improved? Are psychological treatments feasible within the economic and personnel constraints of primary health care? Because the answers are responsive to practical issues in health-care delivery, epidemiologic research designed to probe such matters remains grounded in clinical reality (Williams et al. 1989; Sartorius et al. 1990).

That service orientation distinguishes research on primary care from epidemiologic studies which use symptom counts and cut-off scores to tote up ‘cases’ without reference to disability or to care-seeking behaviour. Preoccupation with internalist criteria and with methodologic precision transmutes the means of research into its ends. Epidemiologists of the latter persuasion will take their cue from Sir William Thomson (1889), later Lord Kelvin, who wrote:

When you can measure what you are speaking about, and express it in numbers, you know something about it, but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.

(Thomson 1889)

Sir William’s statement epitomizes the positivism (and the arrogance) of modern reductionistic science. For too many, I fear, it will suffice for a description of epidemiology, a science whose findings are, after all, ‘expressed in numbers’. Indeed, as the methods of epidemiology become more precise and its mathematics more elegant, its practitioners harbour the hope that the ‘real’ scientists on the medical faculty (the ‘basic’ scientists) will accept epidemiology as a legitimate intellectual enterprise.*

* That such a day is not quite upon us is evident from a conversation with a distinguished biochemist (and an altogether remarkable human being). He had no objection, my colleague told me, to the first US Surgeon General’s warning printed on cigarette packages to the effect that ‘Smoking may be Dangerous to Your Health’. That fair enough. But he (though a non-smoker) was indignant at the new message which has replaced it: ‘Cigarettes Cause Cancer’. He insisted that because the precise mechanism of carcinogenesis has not yet been deciphered, public health authorities have no right to say ‘cause’, whatever the strength of the epidemiologic evidence.

But epidemiology (like all science) is far more than measurements and numbers. Recall the rejoinder by Jacob Viner, late Professor of Economics at Princeton, to Kelvin’s dictum: ‘When you can measure it, when you can express it in numbers, your knowledge is still of a meager and unsatisfactory kind!’ His remark was not intended as a clever and cynical riposte. He went on to explain: ‘It is a mistake to measure for measurement’s sake and to let the possibilities of measurement be decisive as to the range of problems to be investigated.’ I recount this interchange (Merton et al. 1984) because there is a not inconsiderable danger that the remarkable progress in the methods of psychiatric epidemiology in recent decades may lead to so narrow a preoccupation with methodologic elegance as to obscure the fundamental social purposes of the endeavour.

Some years ago I encountered a graduate student who had passed his orals but was in a quandary about choosing a suitable thesis problem. Referred to me by a colleague, he asked if I could identify a topic for him in child psychiatry. The one stricture he placed on my advice was that the study be framed in such fashion that the data collected would be suitable for analysis of variance, the only statistical technique he had mastered! ANOVA seemed quite elegant to him; he wasn’t up to more advanced methods; and he hated the thought of wasting the effort he had put into learning ANOVA by not using it for his thesis!

My account is not invented; the student and his request were real. If his having so far lost the purpose of the research thesis required for his doctorate seems bizarre to you, do not condemn the hapless lad too hastily. Recall the faculty colleagues responsible for the legion of clinical studies that follow upon the availability of a new (preferably automated) method for measuring a presumptively important metabolite in blood, urine or cerebrospinal fluid. Has not psychiatric epidemiology seen its share of studies in which structured interviews and diagnostic algorithms have been pressed into use to obtain ‘answers’ to unasked questions? Some such investigations compute rates of ‘caseness’ that defy clinical judgement, unless, of course, one has as keen a diagnostic eye as the first year surgical registrar who commented, as he scanned a crowd of pedestrians: ‘Look at them; they’re all pre-op!’

Wade Hampton Frost (1936), in his introduction to a reprint of John Snow’s work on cholera, reminded the reader:

Epidemiology at any given time is something more than the total of its established facts. It includes their orderly arrangement into chains of inference which extend more or less beyond the bounds of direct observation. Such of these chains as are well and truly laid guide investigation to the facts of the future; those that are ill-made fetter progress.

(1936: ix)

In addition to its utility in testing hypotheses about the causes of diseases, J.N. Morris (1975) highlights among the uses of epidemiology its roles as ‘the intelligence service of public health’ and as ‘a main method of studying the social aspects of health and disease’. During the nineteenth century, epidemiologic data fuelled the social reform movement; in turn, the passion of social reformers spurred the extension of the epidemiologic paradigm into new areas of inquiry. When Rudolf Virchow inaugurated the journal Die Medizinische Reform in 1847, he announced that ‘medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged’ (Virchow, cited in Rosen 1947). Virchow and his friends emphasized the scientific (that is, epidemiologic) study of the social and economic conditions that influence health. The epidemiologic data base provided the rationale for social measures designed to promote health and prevent disease (Eisenberg 1984).

In London, Edwin Chadwick’s 1842 Report on the Sanitary Conditions of the Labouring Population documented the disproportionate concentration of disease among the working classes; just eight years earlier, Chadwick had been a principal architect of the Poor Law Amendment Act (Webster 1990). He then argued that the ‘profligacy’ of poor relief was demoralizing to its recipients; on further study, the facts led him to conclude that it was filthy living conditions that spawned ‘moral turpitude’ rather than the other way round (Acheson 1990). For his data, he was largely dependent upon William Farr, the Registrar General. Just how committed Farr himself was to the movement for reform is evident from what he wrote in 1843:

Over the supply of water – the sewerage – the burial places – the width of streets – the removal of public nuisances – the poor can have no command … and it is precisely upon these points that the Government can interfere with most advantage. The Legislature would enact the removal of known sources of disease, and, if necessary, trench upon the liberty of the subject and the privilege of property, upon the same principle that it arrests and removes murderers, who, if left unmolested, would probably only destroy lives by hundreds, while the physical causes which have been averted to in this paper, destroy thousands – hundreds of thousands of lives.

(Farr, cited in Wohl 1983)

Similar notes sounded in America. John C. Griscom, City Inspector of the New York Board of Health, was inspired by Chadwick, as is evident from the title of his 1848 book: The Sanitary Condition of the Laboring Population of New York. He noted first, ‘that there is an immense amount of sickness, physical disability, and premature mortality, among the poorer classes’; second, ‘that these are, to a large extent, unnecessary, being in a great degree the results of causes which are removable’; third, ‘that these physical evils are productive of moral evils of great magnitude and number, and which, if considered only in a pecuniary point of view should arouse the government and individuals to the consideration of the best means for their relief and prevention’; and fourth, that it was the responsibility of health officers ‘to suggest the means of alleviating these evils and preventing their recurrence to so great an extent’. By analysing the associations between living conditions and expectations of survival, notable successes in achieving sanitary reforms were won, well before the germ theory of disease was established (Rosen 1958).

Then as now, public-health policy decisions reflect value judgements -informed by science but value judgements none the less; thus they are, in the final analysis, political decisions. Virchow (1848) put the matter succinctly: ‘Medicine is a social science, and politics is nothing more than medicine on a large scale.’ The role of political constituencies in health-policy debates is most evident in an historical instance in which neither the ‘liberals’ nor the ‘conservatives’ grasped the cause or mode of tra...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of figures and tables
• List of contributors
• Preface
• Part I Psychiatric epidemiology and general practice: the development of a research field
• Part II Psychiatric field surveys in the primary health-care setting: an international perspective
• Part III Psychiatric and general medical services: issues of patient selection, referral and treatment
• Part IV Late-life mental disorders and primary health care
• Part V Problems of method: case-finding, classification and taxonomy
• Index