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March 18, 1992, Vol 267, No. 11 >
ARTICLE | March 18, 1992

Service Utilization and Social Morbidity Associated With Depressive Symptoms in the Community FREE

Jim Johnson, PhD; Myrna M. Weissman, PhD; Gerald L. Klerman, MD
[+] Author Affiliations

Dr Johnson died January 10, 1992.

Reprint requests to New York State Psychiatric Institute, Box 14, 722 W 168th St, New York, NY 10032 (Dr Weissman).


JAMA. 1992;267(11):1478-1483. doi:10.1001/jama.1992.03480110054033
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References

Objective.  —To estimate service utilization and social morbidity in the community associated with depressive symptoms. Estimates were made using an epidemiologic measure, population attributable risk. Population attributable risk is a compound measure reflecting both the morbid risk to an individual with a disorder and the prevalence of the disorder in the community.

Design.  —Epidemiologic survey.

Participants.  —Eighteen thousand five hundred seventy-one adults in the Epidemiologic Catchment Area Study interviewed from a complex random sample in five US communities.

Outcome Measures.  —Suicide attempts, use of psychoactive medications, self-reported physical and emotional health, time lost from work, and general medical services or use of emergency departments for emotional problems.

Results.  —Major depression-dysthymia (lifetime prevalence, 6.1%) and depressive symptoms (lifetime prevalence, 23.1%) were associated with increased service utilization and social morbidity as measured by the outcome variables. On a population basis, however, as much or more service burden and impairment was associated with depressive symptoms as with the clinical conditions of depression or dysthymia. The equal association results from the greater prevalence of depressive symptoms. Population attributable risk percentages associated with depressive symptoms (not disorder) were as follows: emergency department use (11.8%) or medical consultations for emotional problems (21.5%); use of tranquilizers (14.6%), sleeping pills (21.0%), or antidepressants (22.2%); fair or poor self-reported emotional health (15.3%); days lost from work (17.8%); and suicide attempts (25.0%).

Conclusions.  —Estimates of population attributable risk indicated that physicians actually provided services to more persons with depressive symptoms than to persons with formally defined conditions of depressive disorders. Subclinical depression, as a consequence of high prevalence, is a clinical and public health problem. Attention to diagnostic and treatment issues is indicated.(JAMA. 1992;267:1478-1483)

REFERENCES

1 +
Boyd JH, Weissman MM.  Epidemiology of affective disorders: a reexamination and future directions. Arch Gen Psychiatry . 1981;;38:1039-1046.
2 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA . 1990;;264:2524-2528.
3 +
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA . 1989;;262:914-919.
4 +
Kelsey JL, Thompson WD, Evans AS. Methods in Observational Epidemiology . New York, NY: Oxford University Press; 1986;:39-41.
5 +
American Psychiatric Association, Task Force on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
6 +
Julius S, Jamerson K, Mejia A, Krause L, Schork N, Jones K.  The association of borderline hypertension with target organ changes and higher coronary risk: Tecumseh Blood Pressure Study. JAMA . 1990;;264:354-358.
7 +
Janerich DT, Thompson WD, Varela LR, et al.  Lung cancer and exposure to tobacco smoke in the household. N Engl J Med . 1990;;323:632-636.
8 +
Rothman K. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;.
9 +
Greenland S, Robins JM.  Conceptual problems in the definition and interpretation of attributable fractions. Am J Epidemiol . 1988;;128:1185-1197.
10 +
Regier DA, Myers JK, Kramer M, et al.  The NIMH Epidemiologic Catchment Area Program: historical context, major obstacles, and study population characteristics. Arch Gen Psychiatry . 1984;;41:934-941.
11 +
Eaton WW, Kessler LG. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
12 +
Sargeant JK, Bruce ML, Florio LP, Weissman MM.  Factors associated with one year outcome of major depression in the community. Arch Gen Psychiatry . 1990;;47:519-526.
13 +
Weissman MM, Leaf PJ, Bruce ML, Florio L.  The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment. Am J Psychiatry . 1988;;145:815-819.
14 +
Klerman GL.  Depression and related disorders of mood.  In: Nicholi AM, ed. The New Harvard Guide to Psychiatry . Boston, Mass: Harvard University Press; 1988;:309-336.
15 +
Spitzer RL, Endicott J, Robins E.  Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry . 1978;;35:773-782.
16 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
17 +
World Health Organization. International Classification of Diseases . Geneva, Switzerland: World Health Organization; 1991;. Draft, 10th revision.
18 +
Regier DA, Farmer ME, Rae DS, et al.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA . 1990;;264:2511-2518.
19 +
Maser JD, Cloninger CR, eds. Comorbidity of Mood and Anxiety Disorders . Washington, DC; American Psychiatric Press; 1990;.
20 +
Greenland S.  Bias in methods for deriving standardized morbidity ratio and attributable fraction estimates. Stat Med . 1984;;3:131-141.
21 +
Robins LN, Heizer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
22 +
Helzer JE, Robins LN, McEvoy LT, et al.  A comparison of clinical and Diagnostic Interview Schedule diagnoses: physician reexamination of layinterviewed cases in the general population. Arch Gen Psychiatry . 1985;;42:657-666.
23 +
Blazer D.  Clinical features in depression in old age: a case for minor depression. Curr Opin Psychiatry . 1991;;4:596-599.
24 +
Cohen P, Cohen J.  The clinician's illusion. Arch Gen Psychiatry . 1984;;41:1178-1182.
25 +
Dohrenwend BP, Shrout PE, Egri G, Mendelsohn FS.  Nonspecific psychological distress and other dimensions of psychopathology: measures for use in the general population. Arch Gen Psychiatry . 1980;;37:1229-1236.

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1 +
Boyd JH, Weissman MM.  Epidemiology of affective disorders: a reexamination and future directions. Arch Gen Psychiatry . 1981;;38:1039-1046.
2 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA . 1990;;264:2524-2528.
3 +
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA . 1989;;262:914-919.
4 +
Kelsey JL, Thompson WD, Evans AS. Methods in Observational Epidemiology . New York, NY: Oxford University Press; 1986;:39-41.
5 +
American Psychiatric Association, Task Force on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
6 +
Julius S, Jamerson K, Mejia A, Krause L, Schork N, Jones K.  The association of borderline hypertension with target organ changes and higher coronary risk: Tecumseh Blood Pressure Study. JAMA . 1990;;264:354-358.
7 +
Janerich DT, Thompson WD, Varela LR, et al.  Lung cancer and exposure to tobacco smoke in the household. N Engl J Med . 1990;;323:632-636.
8 +
Rothman K. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;.
9 +
Greenland S, Robins JM.  Conceptual problems in the definition and interpretation of attributable fractions. Am J Epidemiol . 1988;;128:1185-1197.
10 +
Regier DA, Myers JK, Kramer M, et al.  The NIMH Epidemiologic Catchment Area Program: historical context, major obstacles, and study population characteristics. Arch Gen Psychiatry . 1984;;41:934-941.
11 +
Eaton WW, Kessler LG. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
12 +
Sargeant JK, Bruce ML, Florio LP, Weissman MM.  Factors associated with one year outcome of major depression in the community. Arch Gen Psychiatry . 1990;;47:519-526.
13 +
Weissman MM, Leaf PJ, Bruce ML, Florio L.  The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment. Am J Psychiatry . 1988;;145:815-819.
14 +
Klerman GL.  Depression and related disorders of mood.  In: Nicholi AM, ed. The New Harvard Guide to Psychiatry . Boston, Mass: Harvard University Press; 1988;:309-336.
15 +
Spitzer RL, Endicott J, Robins E.  Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry . 1978;;35:773-782.
16 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
17 +
World Health Organization. International Classification of Diseases . Geneva, Switzerland: World Health Organization; 1991;. Draft, 10th revision.
18 +
Regier DA, Farmer ME, Rae DS, et al.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA . 1990;;264:2511-2518.
19 +
Maser JD, Cloninger CR, eds. Comorbidity of Mood and Anxiety Disorders . Washington, DC; American Psychiatric Press; 1990;.
20 +
Greenland S.  Bias in methods for deriving standardized morbidity ratio and attributable fraction estimates. Stat Med . 1984;;3:131-141.
21 +
Robins LN, Heizer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
22 +
Helzer JE, Robins LN, McEvoy LT, et al.  A comparison of clinical and Diagnostic Interview Schedule diagnoses: physician reexamination of layinterviewed cases in the general population. Arch Gen Psychiatry . 1985;;42:657-666.
23 +
Blazer D.  Clinical features in depression in old age: a case for minor depression. Curr Opin Psychiatry . 1991;;4:596-599.
24 +
Cohen P, Cohen J.  The clinician's illusion. Arch Gen Psychiatry . 1984;;41:1178-1182.
25 +
Dohrenwend BP, Shrout PE, Egri G, Mendelsohn FS.  Nonspecific psychological distress and other dimensions of psychopathology: measures for use in the general population. Arch Gen Psychiatry . 1980;;37:1229-1236.

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