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

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


1
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

2
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

3
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.

4
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.

5
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.

6
Two Examples of International Research
Collaborations
  • The International Consortium in Psychiatric
    Epidemiology (ICPE)
  • The WHOs World Mental Health Survey (WMH)

ICPE
7
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
8
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)

9
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10
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

11
(No Transcript)
12
Lifetime Prevalence of Use, Problems, and
Dependence
ICPE
13
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

14
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.
15
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.
16
Comorbidity of Alcohol, Drug, and Mental
Disorders
ICPE
17
MAPSS
MAPSS
63.6
47.7
34.5
21.3
25.4
18.7
20.5
24.6
12.9
18
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
20
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
21
ICPE
MAPSS
35.5
29.3
19.9
24.6
17.0
18.2
20.5
9.4
12.9
22
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
23
ICPE
MAPSS
63.6
47.7
37.1
25.7
10.7
21.3
24
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
25
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
26
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
27
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
28
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
29
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)

30
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

31
Temporal Ordering of Substance Disorders with
Anxiety and Mood Disorders
ANXIETY SUBSTANCE MOOD
DISORDERS DISORDERS DISORDERS
32
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

33
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

34
The WHOs World Mental Health Survey
An Overview
35
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
36
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

37
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

38
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39
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

40
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

41
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

42
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

43
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

44
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

45
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46
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47
Participating Countries Sample Type
National Probability Sample
Regional Probability Sample
48
Data Collection Status
Completed
In progress
To be completed
49
Unique Aspects of WMH
  • Large scale, worldwide
  • Same design, translation methods, training, and
    quality control protocols
  • CIDI enhancements
  • Clinical follow-up

50
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

51
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

52
Other WMH Content Areas
  • Service use
  • Pharmacoepidemiology
  • Chronic conditions
  • Tobacco use

53
Other WMH Content Areas
  • Eating disorders
  • Gambling
  • 30-day functioning and symptoms
  • Demographics

54
Other Related Functioning Outcomes
  • Interpersonal (dating, marital, parent-child)
    violence
  • Suicide thoughts, plans, and attempts

55
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

56
Certification Process
  • Sample design description
  • Ethics review verification
  • Translation report
  • Pretest report

57
Certification Process
  • Field progress reports
  • Quality control audit
  • Final field procedures report
  • Data review

58
WMH Study Publications
59
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60
WMH Study Publications
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