Challenges and Opportunities in International Collaborations in Mental Health and Substance Abuse Re

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NHSN 4th Annual National Scientific Conference
International Pre-conference Meeting

• Challenges and Opportunities in International
  Collaborations in Mental Health and Substance
  Abuse Research The WMH Initiative in Latin
  America
• Maria Elena Medina-Mora, Ph.D.National Institute
  of Psychiatry, México
• Sergio A. Aguilar-Gaxiola, M.D., Ph.D.
• California State University, Fresno
• San Antonio, TX
• October 11, 2004

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Presentation Outline

• Why engage in international research
  collaborations
• Examples of two multi-site, cross-cultural,
  international collaborations
• ICPE
• Lifetime prevalence of substance use, problems,
  and dependence
• Comorbidity between substance use and mental
  disorders
• WMH
• Lifetime comorbidities between mental and
  substance disorders
• Challenges and benefits of international
  collaborations

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Why Engage in International Research
Collaborations

• We live in a global society mental and substance
  abuse disorders have no borders.
• The burden of mental and substance disorders in
  communities has grown and communities need to be
  supported by strong and effective health services
  if they are to play an increasing role in
  improving mental health.
• It is important that countries improve their
  capacity to undertake quantitative and
  qualitative research and evaluation relevant to
  service standards and improvement, and to mental
  health promotion.

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Why Engage in International Research
Collaborations

• Improvements in mental health depend on a culture
  of research and evaluation.
• We need to strive to establish a research
  capacity in both qualitative and quantitative
  disciplines in countries.
• Priority public health-oriented research such as
  collection of basic planning information through
  national mental health surveys is needed.
• Assessing the costs of mental disorders and
  investigating cost-effective approaches to the
  management of disorders in developing countries
  is also needed.

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Why Engage in International Research
Collaborations

• Universities, researchers, mental health service
  providers and communities interested in mental
  health determinants and outcomes have limited
  interaction with each other.
• Specific efforts need to be made to facilitate
  interaction among these groups.

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Two Examples of International Research
Collaborations

• The International Consortium in Psychiatric
  Epidemiology (ICPE)
• The WHOs World Mental Health Survey (WMH)

ICPE
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ICPE

• The International Consortium in Psychiatric
  Epidemiology (ICPE) is a consortium funded by the
  US National Institutes of Health
• The main goal of the ICPE is to facilitate
  cross-national comparative epidemiologic studies
  of psychiatric disorders through application of
  uniform diagnostic criteria

http//www.hcp.med.harvard.edu/icpe
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ICPE

• Comprised of researchers from around the world
  who have carried out general population
  epidemiologic surveys of psychiatric disorders
  based on the Composite International Diagnostic
  Interview (CIDI)

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ICPE

• The Principal Investigator is Ronald Kessler,
  Ph.D., Harvard Medical School and the CO-PI is
  Bedirhan Ustun, M.D., the World Health
  Organization
• The administrative home of the ICPE is the Survey
  Research Center (SRC) in the Institute for Social
  Research (ISR) at the University of Michigan
• The ISR is one of the leading academic survey
  research training centers in the world

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Lifetime Prevalence of Use, Problems, and
Dependence
ICPE
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ICPE
DEFINITION OF VARIABLES

• Alcohol Use Lifetime history of alcohol use
  (ever had at least 12 drinks of alcohol in a
  single year)
• Alcohol Problem Lifetime occurrence of at least
  one DSM-III-R Criterion A symptom of alcohol
  abuse or dependence
• Alcohol Dependence Meets lifetime DSM-III-R
  dependence criteria

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ICPE
MAPSS
94.1
94.1
97.1
97.1
95.6
95.6
1.6
52.6
52.6
40.2
40.2
40.7
35.8
40.7
1.1
35.8
44.2
40.0
40.0
44.2
19.8
14.1
16.8
Kessler, Aguilar-Gaxiola, Andrade et al., 2003,
Handbook for Drug Abuse Prevention Theory,
Science, and Practice.
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ICPE
MAPSS
90.6
90.6
82.7
82.7
73.6
8.7
73.6
42.7
42.7
22.5
39.0
39.0
22.5
37.7
8.7
3.5
17.2
1.1
4.8
Kessler, Aguilar-Gaxiola, Andrade et al., 2003,
Handbook for Drug Abuse Prevention Theory,
Science, and Practice.
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Comorbidity of Alcohol, Drug, and Mental
Disorders
ICPE
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MAPSS
MAPSS
63.6
47.7
34.5
21.3
25.4
18.7
20.5
24.6
12.9
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MAPSS
MAPSS
71.0
79.4
72.4
56.7
62.4
63.6
63.5
68.6
37.1
45.6
47.7
57.4
25.7
43.5
34.3
44.4
47.4
36.8
10.7
24.2
33.2
21.3
30.0
17.7
19
ICPE
MAPSS
44.9
40.9
30.2
34.5
25.4
18.7
14.7
13.4
8.7
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ICPE
MAPSS
ICPE
71.0
79.4
55.4
56.7
47.6
63.6
63.5
68.6
37.1
35.5
44.4
45.6
47.7
57.4
43.5
25.7
47.4
36.8
31.1
10.7
21.7
24.2
21.3
9.9
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ICPE
MAPSS
35.5
29.3
19.9
24.6
17.0
18.2
20.5
9.4
12.9
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ICPE
MAPSS
71.0
79.4
40.6
56.7
34.9
63.6
63.5
34.7
31.4
68.6
37.1
24.1
33.2
45.6
47.7
57.4
43.5
30.0
25.7
47.4
10.7
14.8
17.7
21.3
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ICPE
MAPSS
63.6
47.7
37.1
25.7
10.7
21.3
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ICPE
MAPSS
71.0
79.4
56.7
63.6
72.4
63.5
68.6
62.4
37.1
45.6
47.7
57.4
43.9
43.5
25.7
47.4
33.8
10.7
16.1
34.3
21.3
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ICPE
MAPSS
79.4
71.0
63.6
56.7
68.6
63.5
37.1
57.4
47.7
43.5
45.6
25.7
47.4
10.7
21.3
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ICPE
MAPSS
71.0
79.4
100
56.7
83.4
63.6
74.4
63.5
63.4
68.6
37.1
45.6
72.7
47.7
57.4
43.5
55.6
25.7
47.4
60.2
44.3
48.4
10.7
21.3
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ICPE
MAPSS
52.1
63.6
36.9
37.1
47.7
34.8
25.7
34.3
20.9
32.8
10.7
19.8
21.3
26.1
18.1
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ICPE
MAPSS
71.0
79.4
55.0
56.7
43.7
63.6
63.5
45.0
68.6
37.1
45.6
29.6
47.7
57.4
43.5
25.7
47.4
35.5
35.1
10.7
22.7
30.4
21.3
18.1
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ICPE
CONCLUSIONS

• Substance abuse and/or dependence were found to
  co-occur within themselves and with anxiety and
  depressive disorders (and adult antisocial
  behaviors)
• Substance disorders were found to be most
  strongly comorbid within themselves, followed by
  either the depressive or anxiety disorders
  (depending upon comorbid substance disorder)

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ICPE
CONCLUSIONS

• Strong consistency was found for anxiety
  disorders temporally preceding the alcohol and
  drug abuse disorders in both man and women and in
  U.S. and Mexico-born respondents
• Depressive disorders were also consistently found
  to be temporally secondary to alcohol and drug
  abuse disorders for both men and women

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Temporal Ordering of Substance Disorders with
Anxiety and Mood Disorders
ANXIETY SUBSTANCE MOOD
DISORDERS DISORDERS DISORDERS
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ICPE
IMPLICATIONS

• Early intervention and successful treatment of
  mental disorders might help prevent the onset of
  a substantial proportion of substance use
  disorders
• Comparison of age of onset reports for temporally
  primary mental disorders and subsequent substance
  use disorders shows a window of opportunity for
  preventive interventions for most mental disorders

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ICPE
LIMITATIONS

• Results are based on cross-sectional data using
  retrospective recall of lifetime data (age of
  onset) to reconstruct temporal priorities between
  first onsets of substance use disorders and
  mental disorders
• Many people unwilling to admit substance use
  problems or mental disorders to survey
  interviewers

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The WHOs World Mental Health Survey
An Overview
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WMH PIs

• T. Bedirhan Üstün, M.D.
• Assessment Classification Epidemiology Group
• World Health Organization (WHO)
• ustunt_at_who.ch

• Ronald C. Kessler, Ph.D.
• Department of Health Care Policy
• Harvard University Medical School
• kessler_at_hcp.med.harvard.edu

http//www.hcp.med.harvard.edu/wmh/index.html
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WMH PAHO

• Claudio T. Miranda, M.D.
• Mental Health Regional Advisor
• Pan American Health Organization (PAHO)
• mirandac_at_paho.gov

• José Miguel Caldas de Almeida, M.D.
• Coordinator, Mental Health Program
• Pan American Health Organization (PAHO)
• caldasaj_at_paho.gov

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WMH Coordination PAHO Region

• Sergio A. Aguilar-Gaxiola, M.D., Ph.D.
• Coordinator for Latin America and
• the Caribbean of the WMH
  
• sergioa_at_csufresno.edu

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The Core Descriptive Goals of WMH

• To estimate
• Prevalences of mental disorders
• Societal burdens of mental disorders
• Comparative burdens of physical and mental
  disorders
• Rates of unmet need for treatment
• Rates of treatment adequacy

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The Core Analytic Goals of WMH

• To examine
• Modifiable risk factors for onset and course of
  mental disorders
• Barriers to seeking treatment
• Predictors of treatment dropout
• Predictors of treatment adequacy

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Core Nosological Goals

• To support changes in DSM-V and ICD-11 by
• Searching for evidence of taxonicity
• Examining effects of threshold variation on
  external validators

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The Social Policy Messages of WMH

• Mental disorders are top illness-related cost
  drivers of impairment
• Safe and effective treatments are available
• Substantial barriers exist to treatment that
  require structural solutions
• Enhanced outreach and treatment are investment
  opportunities

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The WMH Study Design

• Nationally or regionally representative household
  surveys
• Adults 18 and older
• Subsamples of spouses of target respondents
• Standardized interviewer training and monitoring
• Standardized face-to-face interviews

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The WMH Study Design

• Sample of at least 5000 interviews per country
• Both CAPI and PAPI versions
• Shared training, quality control, and data
  processing protocols

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Participating Countries Sample Type
National Probability Sample
Regional Probability Sample
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Data Collection Status
Completed
In progress
To be completed
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Unique Aspects of WMH

• Large scale, worldwide
• Same design, translation methods, training, and
  quality control protocols
• CIDI enhancements
• Clinical follow-up

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The WMH Instruments

• The WHO Composite International Diagnostic
  Interview (CIDI)
• The WHO Disability Assessment Schedule (WHO-DAS)
• The Structured Clinical Interview for DSM-IV
  (SCID-IV)
• A wide range of clinical severity measures

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The WMH Disorders

• Anxiety disorders GAD, OCD, Panic disorder,
• Phobia, PTSD
• Mood disorders MD, mD, RBD, Bipolar
• disorder I and II
• Substance disorders Alcohol and drug abuse-
• dependence, Nicotine dependence
• Other disorders Pathological gambling, IED,
  Personality disorders, NAP, Eating disorders,
  Adult separation anxiety disorder
• Child disorders ADHD, CD, ODD, SA

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Other WMH Content Areas

• Service use
• Pharmacoepidemiology
• Chronic conditions
• Tobacco use

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Other WMH Content Areas

• Eating disorders
• Gambling
• 30-day functioning and symptoms
• Demographics

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Other Related Functioning Outcomes

• Interpersonal (dating, marital, parent-child)
  violence
• Suicide thoughts, plans, and attempts

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Certification Process

• WHAT Framework for documenting process to ensure
  that WMH
• study protocols are adhered
  to in each country
• WHEN As each major phase of the project is
  completed

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Certification Process

• Sample design description
• Ethics review verification
• Translation report
• Pretest report

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Certification Process

• Field progress reports
• Quality control audit
• Final field procedures report
• Data review

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WMH Study Publications
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WMH Study Publications