Posts

On This Day … 03 May

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1877 – Karl Abraham, German psychoanalyst and author (d. 1925).

Karl Abraham

Karl Abraham (03 May 1877 to 25 December 1925) was an influential German psychoanalyst, and a collaborator of Sigmund Freud, who called him his ‘best pupil’.

Life

Abraham was born in Bremen, Germany. His parents were Nathan Abraham, a Jewish religion teacher (1842-1915) and his wife (and cousin) Ida (1847-1929). His studies in medicine enabled him to take a position at the Burghölzli Swiss Mental Hospital, where Eugen Bleuler practiced. The setting of this hospital initially introduced him to the psychoanalysis of Carl Gustav Jung.

Collaborations

In 1907, he had his first contact with Sigmund Freud, with whom he developed a lifetime relationship. Returning to Germany, he founded the Berliner Society of Psychoanalysis in 1910. He was the president of the International Psychoanalytical Association from 1914 to 1918 and again in 1925.

Karl Abraham collaborated with Freud on the understanding of manic-depressive illness, leading to Freud’s paper on ‘Mourning and Melancholia’ in 1917. He was the analyst of Melanie Klein during 1924-1925, and of a number of other British psychoanalysts, including Edward Glover, James Glover, and Alix Strachey. He was a mentor for an influential group of German analysts, including Karen Horney, Helene Deutsch, and Franz Alexander.

Karl Abraham studied the role of infant sexuality in character development and mental illness and, like Freud, suggested that if psychosexual development is fixated at some point, mental disorders will likely emerge. He described the personality traits and psychopathology that result from the oral and anal stages of development (1921). Abraham observed his only daughter Hilda Abraham reporting on her reaction to enemas and infantile masturbation by her brother. He asked that secrets be shared with him but he was careful to respect her privacy and some reports were not published until after Hilda’s death. Hilda was later to become a psychoanalyst.

In the oral stage of development, the first relationships children have with objects (caretakers) determine their subsequent relationship to reality. Oral satisfaction can result in self-assurance and optimism, whereas oral fixation can lead to pessimism and depression. Moreover, a person with an oral fixation will present a disinclination to take care of him/herself and will require others to look after him/her. This may be expressed through extreme passivity (corresponding to the oral benign suckling substage) or through a highly active oral-sadistic behaviour (corresponding to the later sadistic biting substage).

In the anal stage, when the training in cleanliness starts too early, conflicts may result between a conscious attitude of obedience and an unconscious desire for resistance. This can lead to traits such as frugality, orderliness and obstinacy, as well as to obsessional neurosis as a result of anal fixation (Abraham, 1921). In addition, Abraham based his understanding of manic-depressive illness on the study of the painter Segantini: an actual event of loss is not itself sufficient to bring the psychological disturbance involved in melancholic depression. This disturbance is linked with disappointing incidents of early childhood; in the case of men always with the mother (Abraham, 1911). This concept of the prooedipal “bad” mother was a new development in contrast to Freud’s oedipal mother and paved the way for the theories of Melanie Klein (May-Tolzmann, 1997).

Another important contribution is his work “A short study of the Development of the Libido”, where he elaborated on Freud’s “Mourning and Melancholia” (1917) and demonstrated the vicissitudes of normal and pathological object relations and reactions to object loss.

Moreover, Abraham investigated child sexual trauma and, like Freud, proposed that sexual abuse was common among psychotic and neurotic patients. Furthermore, he argued (1907) that dementia praecox is associated with child sexual trauma, based on the relationship between hysteria and child sexual trauma demonstrated by Freud.

Abraham (1920) also showed interest in cultural issues. He analysed various myths suggesting their relation to dreams (1909) and wrote an interpretation of the spiritual activities of the Egyptian monotheistic Pharaoh Amenhotep IV (1912).

What is Forensic Psychiatry?

Published on by Andrew MarshallLeave a comment

Introduction

Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry.

According to the American Academy of Psychiatry and the Law, it is defined as “a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment.”

A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.

Court Work

Forensic psychiatrists work with courts in evaluating an individual’s competency to stand trial, defences based on mental disorders (e.g. the insanity defence), and sentencing recommendations. The two major areas of criminal evaluations in forensic psychiatry are competency to stand trial (CST) and mental state at the time of the offense (MSO).

Competency to Stand Trial

Competency to stand trial (CST) is the competency evaluation to determine that defendants have the mental capacity to understand the charges and assist their attorneys. In the United States, this is seated in the Fifth Amendment to the United States Constitution, which ensures the right to be present at one’s trial, to face one’s accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: “preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants’ decision-making autonomy”.

In 1960, the Supreme Court of the United States in Dusky v. United States established the standard for federal courts, ruling that “the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him.” The evaluations must assess a defendant’s ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defence counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney, and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement.

In England, Wales, Scotland, and Ireland, a similar legal concept is that of “fitness to plead”.

As an Expert Witness

Forensic psychiatrists are often called to be expert witnesses in both criminal and civil proceedings. Expert witnesses give their opinions about a specific issue. Often, the psychiatrist will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, from Thomas Gutheil (2009) to Robert Simon and Liza Gold (2010) and Sadoff (2011) have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry.

Mental State Opinion

Mental state opinion (MSO) gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what he/she was doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards:

  • M’Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong.
  • Durham rule: Excuses a defendant whose conduct is the product of mental disorder.
  • ALI test: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his or her conduct or to conform his conduct to the requirements of law.

“Not guilty by reason of insanity” (NGRI) is one potential outcome in this type of trial. Importantly, insanity is a legal and not a medical term. Often, psychiatrists may be testifying for both the defence and the prosecution.

Forensic psychiatrists are also involved in the care of prisoners, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts (such as those who have been found not guilty by reason of insanity).

Risk Management

Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management.

Risk assessment and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining “static” indicators from personal history and offense details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of “dynamic” risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a “structured professional judgment.” The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers. These schemes may be based on published assessments such as the HCR-20 (which incorporates 10 Historical, 5 Clinical and 5 Risk Management factors) and the risk of sexual violence protocol from Simon Fraser University, BC.

United Kingdom

In the UK, most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or high secure hospitals (also known as special hospitals), of which three are in England and one in Scotland (the State Hospital, Carstairs), the best known of which is Broadmoor Hospital. The other ‘specials’ are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system.

Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those suffering from schizophrenia. Some units also treat people with severe personality disorder or learning disabilities. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence.

Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals (or specialised community-based units with a similar regimen, as the hospitals have mostly been closed). This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also.

Court work (medicolegal work) is generally undertaken as private work by psychiatrists (most often forensic psychiatrists), as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission (used to be called Legal Aid).

Canada

Criminal Law Framework

In Canada, certain credentialed medical practitioners may, at their discretion, make state-sanctioned investigations into and diagnosis of mental illness. Appropriate use of the DSM-IV-TR is discussed in its section entitled “Use of the DSM-IV-TR in Forensic Settings”.

Concerns have been expressed that the Canadian criminal justice system discriminates based on DSM IV diagnosis within the context of Part XX of the Criminal Code. This part sets out provisions for, among other things, court ordered attempts at “treatment” before individuals receive a trial as described in section 672.58 of the Criminal Code. Also provided for are court ordered “psychiatric assessments”. Critics have also expressed concerns that use of the DSM-IV-TR may conflict with section 2(b) of the Canadian Charter of Rights and Freedoms, which guarantees the fundamental freedom of “thought, belief, opinion, and expression”.

Confidentiality

The position of the Canadian Psychiatric Association holds, “in recent years, serious incursions have been made by governments, powerful commercial interests, law enforcement agencies, and the courts on the rights of persons to their privacy.” It goes on to state, “breaches or potential breaches of confidentiality in the context of therapy seriously jeopardize the quality of the information communicated between patient and psychiatrist and also compromise the mutual trust and confidence necessary for effective therapy to occur.”

An outline of the forensic psychiatric process as it occurs in the province of Ontario is presented in the publication The Forensic Mental Health System In Ontario: An Information Guide published by the Centre for Addiction and Mental Health in Toronto. The Guide states: “Whatever you tell a forensic psychiatrist and the other professionals assessing you is not confidential.” The Guide further states: “The forensic psychiatrist will report to the court using any available information, such as: police and hospital records, information given by your friends, family or co-workers, observations of you in the hospital.” Also according to the Guide: “You have the right to refuse to take part in some or all of the assessment. Sometimes your friends or family members will be asked for information about you. They have the right to refuse to answer questions, too.”

Of note, the emphasis in the guide is on the right to refuse participation. This may seem unusual given that a result of a verdict of “Not Criminally Responsible by reason of Mental Disorder” is often portrayed as desirable to the defence, similar to the insanity defence in the United States. A verdict of “Not Criminally Responsible” is referred to as a “defence” by the Criminal Code. However, the issue of the accused’s mental state can also be raised by the Crown or by the court itself, rather than solely by the defence counsel, differentiating it from many other legal defences.

Treatment/Assessment Conflict

In Ontario, a court-ordered inpatient forensic assessment for criminal responsibility typically involves both treatment and assessment being performed with the accused in the custody of a single multidisciplinary team over a 30- or 60-day period. Concerns have been expressed that an accused may feel compelled on ethical, medical, or legal grounds to divulge information, medical, or otherwise, to assessors in an attempt to allow for and ensure safe and appropriate treatment during that period of custody.

Some Internet references address treatment/assessment conflict as it relates to various justice systems, particularly civil litigation in other jurisdictions. The American Academy Of Psychiatry and the Law states in its ethics guidelines, “when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply”, which may be seen as contradiction.

South Africa

In South Africa, patients are referred for observation for a period of 30 days by the courts if questions exist as to CST and MSO. Serious crimes require a panel, which may include two or more psychiatrists. Should the courts find the defendant not criminally responsible, the defendant may become a state patient and be admitted in a forensic psychiatric hospital. They are referred to receive treatment for an indefinite period, but most were back in the community after three years.

Training Standards

Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States, one-year fellowships are offered in this field to psychiatrists who have completed their general psychiatry training. Such psychiatrists may then be eligible to sit for a board certification examination in forensic psychiatry. In Britain, one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one’s general psychiatry training, before receiving a Certificate of Completion of Training as a forensic psychiatrist. In some countries, general psychiatrists can practice forensic psychiatry, as well. However, other countries, such as Japan, require a specific certification from the government to do this type of work.

References

Gutheil, T.G. (2009) The Psychiatrist as Expert Witness. 2nd Ed. Washington: American Psychiatric Publishing.

Robert, S. & Gold, L. (Eds). (2010) American Psychiatric Textbook of Forensic Psychiatry. Washington: American Psychiatric Publishing.

Sadoff, R.L. (2011). Ethical Issues in Forensic Psychiatry: Minimizing Harm. New Jersey: Wiley-Blackwall.

On This Day … 02 May

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1946 – Peter L. Benson, American psychologist and academic (d. 2011).

Peter L. Benson

Peter Lorimer Benson (02 May 1946 to 02 October 2011) was a psychologist and CEO/President of Search Institute. He pioneered the developmental assets framework, which became the predominant approach to research on positive facets of youth development.

According to Scales and Roehlkepartain (2012, p.322):

When [Benson] introduced the developmental assets [approach] in 1989, the predominant approach to youth development was naming youth problems and trying to prevent them. In contrast, the assets approach focused on building strengths. The developmental assets framework became the predominant positive youth development approach in the world, cited more than 17,000 times, and the framework and surveys developed to measure the assets have been used with more than 3 million youths in more than 60 countries.

Reference

Scales, P.C. & Roehlkepartain, E.C. (2012) Peter Lorimer Benson (1946-2011). American Psychologist. 67(4), pp.322. doi:10.1037/a0028171

What is the National Institute of Mental Health?

Published on by Andrew Marshall2 Comments

Introduction

The National Institute of Mental Health (NIMH) is one of 27 institutes and centres that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research.

NIMH is the largest research organisation in the world specialising in mental illness. The institute was first authorised by the US government in 1946, when then President Harry Truman signed into law the National Mental Health Act, although the institute was not formally established until 1949.

NIMH is a $1.5 billion enterprise, supporting research on mental health through grants to investigators at institutions and organisations throughout the United States and through its own internal (intramural) research effort. The mission of NIMH is “to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure.”

In order to fulfil this mission, NIMH “must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.”

Research Priorities

NIMH has identified four overarching strategic objectives for itself:

  • Promote discovery in the brain and behavioural sciences to fuel research on the causes of mental disorders.
  • Chart mental illness trajectories to determine when, where and how to intervene.
  • Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses.
  • Strengthen the public health impact of NIMH-supported research.

Brief History

Organisational History

Throughout its history the NIMH has witnessed a number of name and organisational changes, including:

  • PHS Narcotics Division (1929-1930).
  • PHS Division of Mental Hygiene (1930-1943).
  • Mental Hygiene Division, within the PHS Bureau of Medical Services (1943-1949).
  • National Institute of Mental Health (NIMH), one of the National Institutes of Health (NIH, 1949-1967).
  • NIMH as an independent division of the PHS (1967-1968).
  • NIMH, within the Health Services and Mental Health Administration (1968-1973).
  • NIMH, within NIH (1973).
  • NIMH, within the Alcohol, Drug Abuse, and Mental Health Administration (1973-1992).
  • NIMH, within NIH (1992-present).

In 1992, when the Alcohol, Drug Abuse, and Mental Health Administration was abolished, NIMH was transferred to NIH, retaining its research functions while its treatment services were transferred to the new Substance Abuse and Mental Health Services Administration.

Functions

Mental health has traditionally been a state responsibility, but after World War II there was increased lobbying for a federal (national) initiative. Attempts to create a National Neuropsychiatric Institute failed. Robert H. Felix, then head of the Division of Mental Hygiene, orchestrated a movement to include mental health policy as an integral part of federal biomedical policy. Congressional subcommittees hearings were held and the National Mental Health Act was signed into law in 1946. This aimed to support the research, prevention and treatment of psychiatric illness, and called for the establishment of a National Advisory Mental Health Council (NAMHC) and a National Institute of Mental Health. On 15 April 1949, the NIMH was formally established, with Felix as director. Funding for the NIMH grew slowly and then, from the mid-1950s, dramatically. The institute took on a highly influential role in shaping policy, research and communicating with the public, legitimising the importance of new advances in biomedical science, psychiatric and psychological services, and community-based mental health policies.

In 1955 the Mental Health Study Act called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” The resulting Joint Commission on Mental Illness and Health prepared a report, “Action for Mental Health”, resulting in the establishment of a cabinet-level interagency committee to examine the recommendations and determine an appropriate federal response.

In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centres Construction Act, beginning a new era in Federal support for mental health services. NIMH assumed responsibility for monitoring the Nation’s community mental health centres (CMHC) programmes.

During the mid-1960s, NIMH launched a campaign on special mental health problems. Part of this was a response to President Lyndon Johnson’s pledge to apply scientific research to social problems. The institute established centres for research on schizophrenia, child and family mental health, suicide, as well as crime and delinquency, minority group mental health problems, urban problems, and later, rape, aging, and technical assistance to victims of natural disasters.

Alcohol abuse and alcoholism did not receive full recognition as a major public health problem until the mid-1960s, when the National Centre for Prevention and Control of Alcoholism was established as part of NIMH; a research program on drug abuse was inaugurated within NIMH with the establishment of the Centre for Studies of Narcotic and Drug Abuse.

In 1967, NIMH separated from NIH and was given bureau status within PHS. However, NIMH’s intramural research program, which conducted studies in the NIH Clinical Centre and other NIH facilities, remained at NIH under an agreement for joint administration between NIH and NIMH. Secretary of Health, Education, and Welfare John W. Gardner transferred St. Elizabeth’s Hospital, the Federal Government’s only civilian psychiatric hospital, to NIMH.

In 1968, NIMH became a component of PHS’s Health Services and Mental Health Administration (HSMHA).

In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (P.L. 91-616) established the National Institute of Alcohol Abuse and Alcoholism within NIMH.

In 1972, the Drug Abuse Office and Treatment Act established a National Institute on Drug Abuse within NIMH.

In 1973, NIMH went through a series of organisational moves. The institute temporarily re-joined NIH on 01 July with the abolishment of HSMHA. Then, the DHEW secretary administratively established the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) – composed of the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and NIMH – as the successor organisation to HSMHA. ADAMHA was officially established in 1974.

The President’s Commission on Mental Health in 1977 reviewed the mental health needs of the nation and to make recommendations to the president as to how best meet these needs in 1978.

In 1980 The Epidemiologic Catchment Area (ECA) study, an unprecedented research effort that entailed interviews with a nationally representative sample of 20,000 Americans was launched. The field interviews and first wave analyses were completed in 1985. Data from the ECA provided a picture of rates of mental and addictive disorders and services usage.

The Mental Health Systems Act of 1980 – based on recommendations of the President’s Commission on Mental Health and designed to provide improved services for persons with mental disorders – was passed. NIMH participated in development of the National Plan for the Chronically Mentally Ill, a sweeping effort to improve services and fine-tune various Federal entitlement programs for those with severe, persistent mental disorders.

In 1987, administrative control of St. Elizabeth’s Hospital was transferred from the NIMH to the District of Columbia. NIMH retained research facilities on the grounds of the hospital. The NIMH Neuroscience Centre and the NIMH Neuropsychiatric Research Hospital, located on the grounds of St. Elizabeth’s Hospital, were dedicated in 1989.

In 1992, Congress passed the ADAMHA Reorganisation Act, abolishing ADAMHA. The research components of NIAAA, NIDA and NIMH re-joined NIH, while the services components of each institute became part of a new PHS agency, the Substance Abuse and Mental Health Services Administration (SAMHSA). The return to NIH and the loss of services functions to SAMHSA necessitated a realignment of the NIMH extramural program administrative organisation. New offices were created for research on Prevention, Special Populations, Rural Mental Health and AIDS.

In 1994 The House Appropriations Committee mandated that the director of NIH conduct a review of the role, size, and cost of all NIH intramural research programmes (IRP). NIMH and the National Advisory Mental Health Council (NAMHC) initiated a major study of the NIMH Intramural Research Programme. The planning committee recommended continued investment in the IRP and recommended specific administrative changes; many of these were implemented upon release of the committee’s final report; other changes – for example, the establishment of a major new programme on Mood and Anxiety Disorders – have been introduced in the years since.

In 1996 NIMH, with the NAMHC, initiated systematic reviews of a number of areas of its research portfolio, including the genetics of mental disorders; epidemiology and services for child and adolescent populations; prevention research; clinical treatment and services research. At the request of the National Institute for Mental Health director, the NAMH Council established programmatic groups in each of these areas. NIMH (National Institute of Mental Health) continued to implement recommendations issued by these Workgroups.

In 1997, NIMH realigned its extramural organisational structure to capitalise on new technologies and approaches to both basic and clinical science, as well as changes that had occurred in health care delivery systems, while retaining the Institute’s focus on mental illness. The new extramural organisation resulted in three research divisions: Basic and Clinical Neuroscience Research; Services and Intervention Research; and Mental Disorders, Behavioural Research and AIDS.

Between 1997 and 1999 NIMH refocused career development resources on early careers and added new mechanisms for clinical research.

In 1999 The NIMH Neuroscience Centre/Neuropsychiatric Research Hospital was relocated from St. Elizabeth’s Hospital in Washington, D.C. to the NIH Campus in Bethesda, Maryland, in response to the recommendations of the 1996 review of the NIMH (National Institute of Mental Health) Intramural Research Programme by the IRP Planning Committee.

The first White House Conference on Mental Health, held 07 June, in Washington, D.C., brought together national leaders, mental health scientific and clinical personnel, patients, and consumers to discuss needs and opportunities. The National Institute on Mental Health developed materials and helped organise the conference.

US Surgeon General David Satcher released The Surgeon General’s Call To Action To Prevent Suicide, in July, and the first Surgeon General’s Report on Mental Health, in December. NIMH, along with other federal agencies, collaborated in the preparation of both of these landmark reports.

Since the appointment of Thomas R. Insel as Director of NIMH in 2002, the institute has undergone organisational changes to better target mental health research needs (the expansion from three extramural divisions to five divisions, with the two new divisions focusing on adult and child translational research). NIMH also weathered several years of controversy due to conflict of interest and ethics violations by some of its intramural investigators. This situation cast light on an area that affected all of NIH, and resulted in more stringent rules about conflict of interest for all of NIH. Recently, Congressional interest turned to ethics and conflict of interest concerns with external investigators who receive NIMH or other NIH support. Current federal law has responsibility for managing and monitoring conflict of interests for external investigators with their home institutions/organisations. NIH responded to these new concerns by initiating a formal process for seeking public input and advice that will likely result in a change to the rules for monitoring and managing conflict of interest concerns for externally supported investigators. Finally, the past decade has also been marked by exciting scientific breakthroughs and efforts in mental illness research, as new genetic advances and bioimaging methodologies have increased understanding of mental illnesses. Two notable consequences of these advances are the Institute’s collaboration with the Department of Army to launch the Study To Assess Risk and Resilience in Service Members (STARRS), a Framingham-like effort scheduled to last until 2014 and the Research Domain Criteria (RDoC) effort, which seeks to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple levels of analysis, from genes to neural circuits to behaviours, cutting across disorders as traditionally defined.

A collection of interviews with directors and individuals significant in the foundation and early history of the institute conducted by Dr. Eli A. Rubenstein between 1975 and 1978 is held at the National Library of Medicine in Bethesda, Maryland.

Noted Researchers

In 1970, Julius Axelrod, a NIMH researcher, won the Nobel Prize in Physiology or Medicine for research into the chemistry of nerve transmission for “discoveries concerning the humoral transmitters in the nerve terminals and the mechanisms for their storage, release and inactivation.” He found an enzyme that terminated the action of the nerve transmitter, noradrenaline in the synapse and which also served as a critical target of many antidepressant drugs.

In 1960s-70s John B. Calhoun, ethologist and behavioural researcher studied the population density and its effects on behaviour in the NIMH facility in Maryland. Later his work become renowned after several publications, including article in Scientific American and a widely known “Universe 25” story predicting anti-utopian future based on rodent experiments in overpopulated environment.

In 1984, Norman E. Rosenthal, a psychiatrist and NIMH researcher, pioneered seasonal affective disorder, coined the term SAD, and began studying the use of light therapy as a treatment. He received the Anna Monika Foundation Award for his research on seasonal depression.

Louis Sokoloff, a NIMH researcher, received the Albert Łasker award in Clinical Medical Research for developing a new method of measuring brain function that contributed to basic understanding and diagnosis of brain diseases. Roger Sperry, a NIMH research grantee, received the Nobel Prize in Medicine or Physiology for discoveries regarding the functional specialisation of the cerebral hemispheres, or the “left” and “right” brain.

Eric Kandel and Paul Greengard, each of whom have received NIMH support for more than three decades, shared the Nobel Prize in Physiology or Medicine with Sweden’s Arvid Carlsson. Kandel received the prize for his elucidating research on the functional modification of synapses in the brain. Initially using the sea slug as an experimental model but later working with mice, he established that the formation of memories is a consequence of short and long-term changes in the biochemistry of nerve cells Greengard was recognised for his discovery that dopamine and a number of other transmitters can alter the functional state of neuronal proteins, and also that such changes could be reversed by subsequent environmental signals.

Nancy Andreasen, a psychiatrist and long-time NIMH grantee, won the National Medal of Science for her groundbreaking work in schizophrenia and for joining behavioural science with neuroscience and neuroimaging. The Presidential Award is one of the nation’s highest awards in science.

Aaron Beck, a psychiatrist, received the 2006 Albert Lasker Award for Clinical Medical Research. Often called “America’s Nobels”, the Laskers are the nation’s most distinguished honour for outstanding contributions to basic and clinical medical research. Beck developed cognitive therapy – a form of psychotherapy – which transformed the understanding and treatment of many psychiatric conditions, including depression, suicidal behaviour, generalised anxiety, panic attacks and eating disorders.

In 2010, Mortimer Mishkin was awarded the National Medal of Science. Mishkin is chief of the NIMH’s Section on Cognitive Neuroscience, and acting chief of its Laboratory of Neuropsychology. He is the first NIMH intramural scientist to receive the medal. Due in part to work spearheaded by Mishkin, science now understands much about the pathways for vision, hearing and touch, and about how those processing streams connect with brain structures important for memory.

What is the Eating Attitudes Test?

Published on by Andrew Marshall1 Comment

Introduction

The Eating Attitudes Test (EAT, EAT-26), created by David Garner, is a widely used 26-item, standardised self-reported questionnaire of symptoms and concerns characteristic of eating disorders.

Background

The EAT is useful in assessing “eating disorder risk” in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

The EAT-26 can be used in non-clinical as well as clinical settings not specifically focused on eating disorders. It can be administered in group or individual settings by mental health professionals, school counsellors, coaches, camp counsellors, and others with interest in gathering information to determine if an individual should be referred to a specialist for evaluation for an eating disorder. It is ideally suited for school settings, athletic programs, fitness centres, infertility clinics, paediatric practices, general practice settings, and outpatient psychiatric departments.

Scale and Referral Index

The EAT-26 uses a six-point scale based on how often the individual engages in specific behaviours. The questions may be answered:

  • Always.
  • Usually.
  • Often.
  • Sometimes.
  • Rarely.
  • Never.

Completing the EAT-26 yields a “referral index” based on three criteria:

  1. The total score based on the answers to the EAT-26 questions;
  2. Answers to the behavioural questions related to eating symptoms and weight loss; and
  3. The individual’s body mass index (BMI) calculated from their height and weight.

Generally, a referral is recommended if a respondent scores “positively” or meets the “cut off” scores or threshold on one or more criteria.

Permission to use the EAT-40 or EAT-26 can be obtained from David Garner through the EAT-26 website. Instructions, scoring, and interpretive information can be obtained from the EAT-26 website at no charge. Completion of the EAT-26 with anonymous feedback on the EAT-26 website is possible.

Brief History

The EAT was developed in response to a National Institute of Mental Health consensus panel that recognized a need for screening large populations to increase early identification of anorexia related symptoms. Additionally, the NIMH wanted a measure that could be used to examine the social and cultural factors involved in the development and maintenance of eating disorders. The original version of the EAT was published in 1979, with 40 items each rated on a 6-point Likert scale. In 1982, Garner and colleagues modified the original version to create an abbreviated 26-item test. The items were reduced after a factor analysis on the original 40-item data set revealed 26 independent items. Since then, the EAT has been translated into many different languages and has gained widespread international as a tool to screen for eating disorders. Both the original paper and the subsequent 1982 publication are 3rd and 4th on the list of the 10 most cited articles in the history of the journal Psychological Medicine, a prominent peer-reviewed journal in the fields of psychology and psychiatry.

The EAT-26 is recommended as the first step in a two-stage screening process. Accordingly, individuals who score higher than a 20 should be referred to a qualified professional to determine if they meet the diagnostic criteria for an eating disorder. The EAT-26 is not designed to make a diagnosis of an eating disorder and should not be used in place of a professional diagnosis or consultation. The EAT should only be used as a screener for general eating disorders, as research has not shown it to be a valid instrument in making specific diagnoses.

Limitations

The EAT suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them. Like all questionnaires, the way the instrument is administered can have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey.

As the EAT was originally developed to screen subjects at high risk for anorexia nervosa (AN), it remains controversial whether its present items and scoring cut-off are well-suited to diagnosing other eating disorders. Although the EAT can adequately diagnose undifferentiated eating disorders in clinical settings, it may not fare well in settings unequipped to address major eating disorders.

While the EAT-26 has demonstrated good internal consistency, its test-retest reliability remains uncertain. The stability of an EAT-26 score has been demonstrated to be moderate over two years, but vulnerable to fluctuations over four years. This may be due to changes in an individual’s eating behaviours and attitudes over time naturally or in response to receiving eating disorder treatment.

Another area of debate is the cut-off score of 20 first proposed by David Garner and colleagues to diagnose anorexia nervosa. High false-positive rates and low predictive power for screening for AN and bulimia nervosa (BN) in non-clinical settings have been reported. Use of the EAT-26 as a screening tool could also result in high false-negative rates in individuals with binge eating disorder (BED) or eating disorders not otherwise specified (EDNOS). Such rates may be due to changes over time in the DSM and ICD criteria for eating disorders from which the items in the EAT are based. Another explanation may be the EAT’s inability to distinguish subthreshold forms of abnormal eating behaviour from clinical eating disorders. Lowering the cut-off score to 11 has been demonstrated to improve sensibility and sensitivity rates in individuals with BN, BED, and EDNOS and presents a promising solution to the aforementioned issue.

On This Day … 01 April

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1851 – Laza Lazarević, Serbian psychiatrist and neurologist (d. 1891).

People (Deaths)

  • 2005 – Kenneth Clark, American psychologist and academic (b. 1914).

Laza Lazarevic

Lazar “Laza” Lazarević (Serbian Cyrillic: Лазаp Лаза Лазаревић, 13 May 1851 to 10 January 1891) was a Serbian physician writer, psychiatrist, and neurologist.

The primary interest of Lazarević throughout his short life was the science of medicine. In that field, he was one of the greatest figures of his time, pre-eminently distinguished and useful as a doctor, teacher, and writer on both medical issues as well as literary themes. To him, literature was an avocation; yet he was talented at it and thought of himself as a man of letters. He translated the works of Nikolay Chernyshevsky and Ivan Turgenev into Serbian.

Few writers have achieved fame with such a small opus as Lazarević, for it rests on nine stories; yet he is considered one of the best Serbian writers of the nineteenth century. He was often referred to as the Serbian Turgenev. During his brief life, “the less than prolific opus” enshrined him in Serbian literature as a writer who introduced the psychological story genre.

Kenneth Clark

Kenneth Bancroft Clark (14 July 1914 to 01 May 2005) and Mamie Phipps Clark (18 April 1917 to August 1983) were American psychologists who as a married team conducted research among children and were active in the Civil Rights Movement. They founded the Northside Centre for Child Development in Harlem and the organization Harlem Youth Opportunities Unlimited (HARYOU). Kenneth Clark was also an educator and professor at City College of New York, and first Black president of the American Psychological Association.

They were known for their 1940s experiments using dolls to study children’s attitudes about race. The Clarks testified as expert witnesses in Briggs v. Elliott (1952), one of five cases combined into Brown v. Board of Education (1954). The Clarks’ work contributed to the ruling of the US Supreme Court in which it determined that de jure racial segregation in public education was unconstitutional. Chief Justice Earl Warren wrote in the Brown v. Board of Education opinion, “To separate them from others of similar age and qualifications solely because of their race generates a feeling of inferiority as to their status in the community that may affect their hearts and minds in a way unlikely to ever be undone.”

Early Life and Education

Kenneth Clark was born in the Panama Canal Zone to Arthur Bancroft Clark and Miriam Hanson Clark. His father worked as an agent for the United Fruit Company. When he was five, his parents separated and his mother took him and his younger sister Beulah to the US to live in Harlem in New York City. She worked as a seamstress in a sweatshop, where she later organized a union and became a shop steward for the International Ladies Garment Workers Union. Clark moved to New York City while the ethnic diversity of Harlem was disappearing, and his school was predominantly black. Clark was trained to learn a trade, as were most black students at this time. Miriam wanted more for her son and transferred him to George Washington High School in Upper Manhattan. Clark graduated from high school in 1931 (Jones & Pettigrew, 2005).

Clark attended Howard University, a historically black university, where he first studied political science with professors including Ralph Johnson Bunche. During his years at Howard University, he worked under the influence of mentor Francis Cecil Sumner, the first African American to receive a doctorate in psychology. He returned in 1935 for a master’s in psychology. Clark was a distinguished member of Kappa Alpha Psi fraternity. After earning his master’s degree, Sumner directed Clark to Columbia University to work with another influential mentor, Otto Klineberg (Jones & Pettigrew, 2005).

While studying psychology for his doctorate at Columbia University, Clark did research in support of the study of race relations by Swedish economist Gunnar Myrdal, who wrote An American Dilemma. In 1940, Clark was the first African American to earn a Ph.D. in psychology from Columbia University.

Career

During the summer of 1941, after Clark was already asked to teach a summer session at City College of New York, the Dean of Hampton Institute asked Clark to start a department of psychology there. In 1942 Kenneth Clark became the first African-American tenured full professor at the City College of New York. Clark also started a psychology department at Hampton Institute in 1942 and taught a few courses within the department. In 1966 he was the first African American appointed to the New York State Board of Regents and the first African American to be president of the American Psychological Association.

Much of Clark’s work came as a response to his involvement in the 1954 Brown v. Board of Education US Supreme Court desegregation decision. Lawyers Jack Greenberg and Robert L. Carter, with resources and funding from the American Jewish Committee (AJC) and Topeka Jewish Community Relations Bureau, hired Clark to present his work on the effects of segregation on children. After the Brown v. Board of Education case, Clark was still dissatisfied by the lack of progress in school desegregation in New York City. In a 1964 interview with Robert Penn Warren for the book Who Speaks for the Negro?, Clark expressed his doubts about the efficacy of certain busing programs in desegregating the public schools. Clark also felt very discouraged by the lack of social welfare organizations to address race and poverty issues. Clark argued that a new approach had to be developed to involve poor blacks, in order to gain the political and economic power needed to solve their problems. Clark called his new approach “internal colonialism”, with hope that the Kennedy-Johnson administration’s War on Poverty would address problems of increasing social isolation, economic dependence and declining municipal services for many African Americans (Freeman, 2008).

Clark in 1962 was among the founders of Harlem Youth Opportunities Unlimited (HARYOU), an organisation devoted to developing educational and job opportunities. With HARYOU, Clark conducted an extensive sociological study of Harlem. He measured IQ scores, crime frequency, age frequency of the population, drop-out rates, church and school locations, quality of housing, family incomes, drugs, STD rates, homicides, and a number of other areas. It recruited educational experts to help to reorganize Harlem schools, create preschool classes, tutor older students after school, and job opportunities for youth who dropped out. The Johnson administration earmarked more than $100 million for the organisation. When it was placed under the administration of a pet project of Congressman Adam Clayton Powell, Jr. in 1964, the two men clashed over appointment of a director and its direction.

Clark used HARYOU to press for changes to the educational system to help improve black children’s performance. While he at first supported decentralisation of city schools, after a decade of experience, Clark believed that this option had not been able to make an appreciable difference and described the experiment as a “disaster.”

Following race riots in the summer of 1967, US President Lyndon Johnson appointed the National Advisory Commission on Civil Disorders (Kerner Commission). The Commission called Clark among the first experts to testify on urban issues. In 1973, Clark testified in the trial of Ruchell Magee.

Clark retired from City College in 1975, but remained an active advocate for integration throughout his life, serving on the board of the New York Civil Rights Coalition, of which he was Chairman Emeritus until his death. He opposed separatists and argued for high standards in education, continuing to work for children’s benefit. He consulted to city school systems across the country, and argued that all children should learn to use Standard English in school.

What is Cognitive Neuropsychiatry?

Published on by Andrew Marshall2 Comments

Introduction

Cognitive neuropsychiatry is a growing multidisciplinary field arising out of cognitive psychology and neuropsychiatry that aims to understand mental illness and psychopathology in terms of models of normal psychological function.

Background

A concern with the neural substrates of impaired cognitive mechanisms links cognitive neuropsychiatry to the basic neuroscience. Alternatively, CNP provides a way of uncovering normal psychological processes by studying the effects of their change or impairment.

The term “cognitive neuropsychiatry” was coined by Prof Hadyn Ellis (Cardiff University ) in a paper “The cognitive neuropsychiatric origins of the Capgras delusion”, presented at the International Symposium on the Neuropsychology of Schizophrenia, Institute of Psychiatry, London (Coltheart, 2007).

Although clinically useful, current syndrome classifications (e.g. DSM-IV; ICD-10) have no empirical basis as models of normal cognitive processes. No neuropsychological accounts of how the brain ‘works’ would ever be complete without a cognitive level of analysis. CNP moves beyond diagnosis and classification to offer a cognitive explanation for established psychiatric behaviours, regardless of whether the symptoms are due to recognised brain pathology or to dysfunction in brain areas or networks without structural lesions.

CNP has been influential, not least because of its early success in explaining some previously bizarre psychiatric delusions, most notably the Capgras delusion, Fregoli delusion and other delusional misidentification syndromes. The Capgras delusion is “explained as the interruption in the covert route to face recognition, namely affective responses to familiar stimuli, localised in the dorsal route of vision from striate cortex to limbic system. According to standard molecular hypotheses, acute delusions are the result of a dysregulated activity of some neuromodulators.”

Additionally, the study of cognitive neuropsychiatry has shown to intersect with the study of philosophy. This intersection revolves around a reconsideration of the mind-body relationship and the contemplation of moral issues that can arise by fields such as neuropsychopathology. For example, it has been under consideration whether or not Parkinson’s patients should be held morally accountable for their physical actions. This discussion and study has taken place due to the discovery that under certain circumstances, Parkinson’s patients can initiate and control their own movement. Examples such as this are cause for difficult judgement calls, i.e. “about who is mad and who is bad” (Stein 1999). Cognitive neuropsychiatry has also explored the difference between implicit and explicit cognition, especially in catatonic patients. For more information on the bridge between neuropsychiatry and philosophy see (e.g. Stein, 1999).

References

Coltheart, M. (2007) The 33rd Sir Frederick Bartlett Lecture Cognitive Neuropsychiatry and Delusional Belief. Quarterly Journal of Experimental Psychology. https://doi.org/10.1080/17470210701338071.

Stein, D. (1999) Philosophy, Psychiatry, & Psychology 6.3, pp.217-221. https://www.researchgate.net/publication/236774712_Philosophy_and_Cognitive_Neuropsychiatry.

What is Delusional Misidentification Syndrome?

Published on by Andrew Marshall1 Comment

Introduction

Delusional misidentification syndrome is an umbrella term, introduced by Christodoulou (in his book The Delusional Misidentification Syndromes, Karger, Basel, 1986) for a group of delusional disorders that occur in the context of mental and neurological illness.

Refer to Cognitive Neuropsychiatry.

Background

They all involve a belief that the identity of a person, object, or place has somehow changed or has been altered. As these delusions typically only concern one particular topic, they also fall under the category called monothematic delusions.

This psychopathological syndrome is usually considered to include four main variants:

  • The Capgras delusion is the belief that (usually) a close relative or spouse has been replaced by an identical-looking impostor.
  • The Fregoli delusion is the belief that various people the believer meets are actually the same person in disguise.
  • Intermetamorphosis is the belief that an individual has the ability to take the form of another person in both external appearance and internal personality.
  • Subjective doubles, described by Christodoulou in 1978 (American Journal of Psychiatry 135, 249, 1978), is the belief that there is a doppelgänger or double of themselves carrying out independent actions.

However, similar delusional beliefs, often singularly or more rarely reported, are sometimes also considered to be part of the delusional misidentification syndrome. For example:

  • Mirrored-self misidentification is the belief that one’s reflection in a mirror is some other person.
  • Reduplicative paramnesia is the belief that a familiar person, place, object, or body part has been duplicated. For example, a person may believe that they are in fact not in the hospital to which they were admitted, but an identical-looking hospital in a different part of the country, despite this being obviously false.
  • The Cotard delusion is a rare disorder in which people hold a delusional belief that they are dead (either figuratively or literally), do not exist, are putrefying, or have lost their blood or internal organs.
    • In rare instances, it can include delusions of immortality.
  • Syndrome of delusional companions is the belief that objects (such as soft toys) are sentient beings.
  • Clonal pluralisation of the self, where a person believes there are multiple copies themselves, identical both physically and psychologically but physically separate and distinct.

There is considerable evidence that disorders such as the Capgras or Fregoli syndromes are associated with disorders of face perception and recognition. However, it has been suggested that all misidentification problems exist on a continuum of anomalies of familiarity, from déjà vu at one end to the formation of delusional beliefs at the other.

On This Day … 30 April

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1857 – Eugen Bleuler, Swiss psychiatrist and eugenicist (d. 1940).
  • 1878 – Władysław Witwicki, Polish psychologist, philosopher, translator, historian (of philosophy and art) and artist (d. 1948).
  • 1930 – Félix Guattari, French psychotherapist and philosopher (d. 1992).

Eugen Bleuler

Paul Eugen Bleuler (30 April 1857 to 15 July 1939) was a Swiss psychiatrist and eugenicist most notable for his contributions to the understanding of mental illness.

He coined many psychiatric terms, such as “schizophrenia”, “schizoid”, “autism”, depth psychology and what Sigmund Freud called “Bleuler’s happily chosen term ambivalence”.

Bleuler studied medicine in Zürich. He trained for his psychiatric residency at Waldau Hospital under Gottileb Burckhardt, a Swiss psychiatrist, from 1881-1884. He left his job in 1884 and spent one year on medical study trips with Jean-Martin Charcot, a French neurologist in Paris, Bernhard von Gudden, a German psychiatrist in Munich, and to London. After these trips, he returned to Zürich to briefly work as assistant to Auguste Forel while completing his psychiatric residency at the Burghölzli, a university hospital.

Bleuler became the director of a psychiatric clinic in Rheinau, a hospital located in an old monastery on an island in the Rhine. At the time, the clinic was known for being functionally backward and largely ineffective. Because of this, Bleuler set about improving conditions for the patients residing there.

In the year 1898, Bleuler returned to the Burghölzli and became a psychiatry professor at Burghölzli, the same university hospital he completed his residency. He was also appointed director of the mental asylum in Rheinau. He served as the director from the years 1898 to 1927. While working at this asylum, Bleuler cared for long-term psychiatric patients. He also implemented both psychoanalytic treatment and research, and was influenced by Sigmund Freud.

During his time as the director of psychiatry at Burghölzli, Bleuler made great contributions to the field of psychiatry and psychology that made him known today. Because of these findings, Bleuler has been described as one of the most influential Swiss psychiatrists.

Wladyslaw Witwicki

Władysław Witwicki (30 April 1878 to 21 December 1948)] was a Polish psychologist, philosopher, translator, historian (of philosophy and art) and artist. He is seen as one of the fathers of psychology in Poland.

Witwicki was also the creator of the theory of cratism, theory of feelings, and he dealt with the issues of the psychology of religion, and the creation of secular ethics. He was one of the initiators and co-founders of Polish Philosophical Society. He is one of the thinkers associated with the Lwów-Warsaw school.

Witwicki is the author of the first Polish textbooks on psychology. He also collaborated with other philosophers. For instance, he worked with Bronisław Bandrowski to develop a model of psychology based on Franz Brentano’s theory on phenomenology. It included an analysis of Edmund Husserl’s Theory of Content and the Phenomenon of Thinking.

In the comments to his own translation of the Gospels of Matthew and Mark – Dobra Nowina według Mateusza i Marka (The Good News according to Matthew and Mark) – Witwicki challenges the mental health of Jesus. He attributed to Jesus subjectivism, increased sense of his own power and superiority over others, egocentrism and the tendency to subjugate other people, as well as difficulties communicating with the outside world and multiple personality disorder, which made him a schizothymic or even schizophrenic type (according to the Ernst Kretschmer’s typology).

Felix Guattari

Pierre-Félix Guattari (30 April 1930 to 29 August 1992) was a French psychotherapist, philosopher, semiologist, activist and screenwriter.

He founded both schizoanalysis and ecosophy, and is best known for his intellectual collaborations with Gilles Deleuze, most notably Anti-Oedipus (1972) and A Thousand Plateaus (1980), the two volumes of Capitalism and Schizophrenia.

What is the Centre for Epidemiologic Studies Depression Scale?

Published on by Andrew MarshallLeave a comment

Introduction

The Centre for Epidemiologic Studies Depression Scale (CES-D) is a brief self-report questionnaire developed in 1977 by Laurie Radloff to measure depressive symptoms severity in the general population.

The CES-D consists of 20 questions that asks about various symptoms of depression as they have occurred in the past week, and the majority of the items focus on the affective component of depression. Although initially designed for use in general population surveys, CES-D now serves as a screening instrument in primary care clinics and in research.

A revision, the CESD-R was produced in 2004.

Centre for Epidemiologic Studies Depression Scale for Children

The Centre for Epidemiologic Studies Depression Scale for Children (CES-DC) is a modified version of the Centre for Epidemiologic Studies Depression Scale. This measure assesses both depressive symptoms as well as symptom improvement in a wide range of children and adolescents, ages 6-17. The CES-DC was first developed to measure the incidence and prevalence of depression among children and adolescents in large-scale epidemiological research. Several research studies have found the CES-DC to be a reliable and valid measure of depressive symptoms in children.

Question Breakdown and Scoring

The CES-DC is an inventory of 20 self-report items regarding depressive symptoms, taking about 5 minutes to complete. Each item asks how often a symptom has occurred within the last week. Response choices are assigned point values, which are summed together to determine a total measure score. Response choices for each item and their corresponding point values are as follows:

  • 0 points: “Not at all”.
  • 1 point: “A little”.
  • 2 points: “Some”.
  • 3 points: “A lot”.

Items 4, 8, 12 and 16 are phrased to reflect positive affect and behaviour, and therefore are scored in opposite order as follows:

  • 0 points: “A lot”.
  • 1 point: “Some”.
  • 2 points: “A little”.
  • 3 points: “Not at all”.

Interpretation

Scores on the CES-DC range from 0 to 60, in which higher scores suggest a greater presence of depressive symptoms. A score of 15 or higher is interpreted to indicate a risk for depression. However, screening for depression is a complex process and scoring a 15 or higher on the CES-DC should be followed by further evaluation.

Limitations

A study evaluating the CES-DC found that the scores do not necessarily match up to a DSM diagnosis, and while it is a good psychometric tool for adolescents, reliability and validity is poor when applied to children.