Academic literature on the topic 'Mental illness – Epidemiology'

SUMMARYThis is an overview of epidemiology relevant to mental health problems in old age. We start by reviewing some basic terminology: the definitions of prevalence and incidence; the difference between descriptive and analytical epidemiology; the differences between study designs, including cross-sectional, case–control and cohort studies. We then cover the main epidemiological features of the major psychiatric diseases that affect older people (dementia and its different types, depression, late-onset schizophrenia, bipolar affective disorder, delirium, anxiety-related disorders, eating disorders, alcohol and substance misuse, personality disorders) and suicide.We end with some descriptive statistics regarding quality of life in older people.

Computer linkage of an obstetric register and a psychiatric case register made it possible to investigate the temporal relationship between childbirth and psychiatric contact in a population of 470 000 people over a 12-year period resulted in 54 087 births: 120 psychiatric admissions within 90 days of parturition. The ‘relative risk’ of admission to a psychiatric hospital with a psychotic illness was extremely high in the first 30 days after childbirth, particularly in primiparae, suggesting that metabolic factors are involved in the genesis of puerperal psychoses. However, being unmarried, having a first baby, Caesarian section and perinatal death were all associated with an increased risk of psychiatric admission or contact, or both, suggesting that psychological stresses also contribute to this high psychiatric morbidity. Women with a history of manic depressive illness, manic or depressive, had a much higher risk of psychiatric admission in the puerperium than those with a history of schizophrenia or depressive neuroses, and the majority of puerperal admissions met Research Diagnostic Criteria for manic or depressive disorder. Probably, therefore, puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia.

Abstract We examined the risk of any perinatal mental illness associated with prepregnancy diabetes and identified how diabetes duration, complexity, and intensity of care affect this risk. We performed a population-based study of women aged 15–49 years with (n = 14,186) and without (n = 843,818) prepregnancy diabetes who had a singleton livebirth (Ontario, Canada, 2005–2015) and no recent mental illness. Modified Poisson regression estimated perinatal mental illness risk between conception and 1 year postpartum in women with versus without diabetes and in diabetes groups, defined by a latent class analysis of diabetes duration, complexity, and intensity-of-care variables, versus women without diabetes. Women with diabetes were more likely than those without to develop perinatal mental illness (18.1% vs. 16.0%; adjusted relative risk = 1.11, 95% confidence interval: 1.07, 1.15). Latent classes of women with diabetes were: uncomplicated and not receiving regular care (59.7%); complicated, with longstanding diabetes, and receiving regular care (16.4%); and recently diagnosed, with comorbidities, and receiving regular care (23.9%). Perinatal mental illness risk was elevated in all classes versus women without diabetes (adjusted relative risks: 1.09–1.12), but results for class 2 were nonsignificant after adjustment. Women with diabetes could benefit from preconception and perinatal strategies to reduce their mental illness risk.

Perinatal mental disorders are common and can have a profound impact on women and their families. This session will briefly review the epidemiology of disorders in the perinatal period and current evidence on pharmacological and non-pharmacological treatments. The role of the psychiatrist in helping women in their decision-making on treatment will be discussed.Disclosure of interestThe author has not supplied his declaration of competing interest.

Polypharmacy is broadly defined as the administration of more than one medication in a single patient, with the most commonly used definition indicating the concurrent use of five or more medications. Polypharmacy occurs in most clinical settings, particularly inpatient settings and treatment settings for persons with chronic illness and the elderly. Reasons for receiving more than one medication include ineffective treatment with monotherapy, targeting specific but varied symptoms, treating two distinct but co-morbid illnesses, addressing unremitting symptoms, and treating extrapyramidal side effects. Research indicates that each medication added to the patient’s regimen increases the likelihood of an adverse outcome, as well as the risk of adverse drug reactions, drug-to-drug interactions, cumulative toxicity, medication errors, patient non-compliance, patient morbidity, and patient mortality. The current study seeks to investigate the rates of polypharmacy and related characteristics predictive of polypharmacy within a forensic psychiatric setting. A total of 182 patients residing in a secure forensic psychiatric hospital were selected. The sample is predominantly male (80.8%, n=147) and majority Caucasian (55.5%, n=101), African American (40.1%, n=73), and Hispanic (2.2%, n=4), with a mean age of 43.5 (SD=13.2). Participants range from persons with at least one mental health disorder (100%, n=182) to persons with at least one chronic illness (74.5%, n=132). Of those currently taking medications, 99.2% have been prescribed more than one type of medication, with 93.1% of those individuals being prescribed four or more. Polypharmacy was observed in 91% of participants. Of those diagnosed with a mood or psychotic disorder, an average of 3.6 different types of psychotropic medications were prescribed. Co-morbidity of mental illness was predictive of polypharmacy trends, F(1,181)=5.28, p<.05. Additionally, individuals with at least one chronic illness also were subjected to polypharmacy practices, with rates increasing for those with more than one chronic illness. As a measure of onset and severity of symptoms, age at first hospitalization and age of onset of aggressive behaviors were measured, and, interestingly, both measures were predictive of polypharmacy within these patients, F(1, 181)=13.45, p<.01. Results indicate that perceived severity of symptomology, aggression, and complex health problems all contribute to polypharmacy practices among prescribing physicians. The high rates of polypharmacy observed are concerning because of the potential for increased aversive health outcomes. Understanding the predictive factors, rates, and trends of polypharmacy has valuable implications for the future treatment and rehabilitation of individuals residing in a forensic psychiatric setting.

(Truncated abstract) The aims of this thesis are: (i) To estimate the prevalence of psychiatric illness among persons with intellectual disability and, conversely, the prevalence of intellectual disability among persons with a psychiatric illness; (ii) To describe the disability and service utilisation profile of persons with conjoint disorder; (iii) To examine, in particular, intellectual disability co-occurring with schizophrenia; and (iv) To explore the role of hereditary and environmental (specifically obstetric) risk factors in the aetiology of (i) intellectual disability and (ii) intellectual disability co-occurring with psychiatric illness. This thesis has a special interest in the relationship between intellectual disability and schizophrenia. Where data and sample sizes permit, it explores that relationship at some depth and has included sections on the putative nature of the link between intellectual disability and schizophrenia in the introductory and discussion chapters. To realise its objectives, the thesis comprises a core study focusing on aims (i) – (iii) and a supplementary study whose focus is aim (iv). It also draws on work from an ancillary study completed prior to the period of candidacy...This thesis found that, overall, 31.7% of persons with an intellectual disability had a psychiatric illness; 1.8% of persons with a psychiatric illness had an intellectual disability. The rate of schizophrenia, but not bipolar disorder or unipolar major depression, was greatly increased among cases of conjoint disorder: depending on birth cohort, 3.7-5.2% of individuals with intellectual disability had co-occurring schizophrenia. Down syndrome was much less prevalent among conjoint disorder cases despite being the most predominant cause of intellectual disability while pervasive developmental disorder was over-represented. Persons with conjoint disorder had a more severe clinical profile including higher mortality rates than those with a single disability. The supplementary study confirmed the findings in the core body of work with respect to the extent of conjoint disorder, its severity, and its relationship with pervasive development disorder and Down syndrome. Moreover, the supplementary study and the ancillary influenza study indicated a role for neurodevelopmental insults including obstetric complications in the adverse neuropsychiatric outcomes, with timing of the insult a potentially critical element in defining the specific outcome. The supplementary study also added new information on familiality in intellectual disability. It found that, in addition to parental intellectual disability status and exposure to labour and delivery complications at birth, parental psychiatric status was an independent predictor of intellectual disability in offspring as well as a predictor of conjoint disorder. In conclusion, the facility to collect and integrate records held by separate State administrative health jurisdictions, and to analyse them within the one database has had a marked impact on the capacity for this thesis to estimate the prevalence of conjoint disorder among intellectually disabled and psychiatric populations, and to understand more about its clinical manifestations and aetiological underpinnings.

The purpose of this study was to examine the relative risk of psychiatric disorders occurring in patients diagnosed with neurological disorders. This study separately computed the relative risk ratios for identified psychiatric disorder (i.e., anxiety, mood disorders, somatization, schizophrenia, alcohol abuse, and antisocial personality disorder) on seven of the more common neurological disorders (i.e., brain tumor, closed head injury, stroke, dementia, multiple sclerosis, cerebral palsy, and Parkinson's disease). The six psychiatric disorders were chosen based on the epidemiological catchment area (ECA) research (Robins & Reigier 1991) and provided the control group of psychiatric disorders in the general population by which comparisons were made to the neurological care setting. The neurological disorders were included based on the frequency of referrals to a neuropsychological practice. Further, this study provided an overall relative risk ratio of psychiatric disorders for all seven neurological disorders considered together.Participants in this study included a sample of 367 consecutive referrals to a neurology practice in the Midwest. All of the 376 subjects were diagnosed with a neurological disorder. Two hundred forty-six of the subjects were diagnosed with a neurological disorder and no psychiatric disorder. One hundred twenty-one of the subjects were diagnosed with both a neurological and a psychiatric disorder. The MMPI2 was used in the assessment and diagnosis of psychiatric disorders. The control group, represented by the ECA study, was composed of 19,640 participants.Relative risk estimates were made using cross products ratio. Significance of the risk ratio was tested using Chi-square Continuity Correction values. Power analysis was conducted using Fisher's Exact Test.The results of the analysis suggested that patients with neurological disorders are more likely to present with psychiatric disorders compared to the general population. The overall relative risk for this study revealed that patients were 1.669 times more likely to have a comorbid psychiatric disorder following the diagnosis of a neurological disorder. Additionally, three individual disorders had relative risk ratios suggesting an increase in psychiatric disorders above the risk in the general population. These three conditions included stroke (RR = 3.038), dementia (RR = 2.762), and multiple sclerosis (RR = 3.617).
Department of Educational Psychology

Background: Co-occurring substance use disorders (SUDs) occur in as many as half to three quarters of patients with severe mental disorders such as schizophrenia and bipolar disorder, a phenomenon also described as dual diagnosis. Past research from high income countries have shown that the presence of co-occurring SUDs are associated with a number of demographic and clinical factors, including worse clinical outcomes. Although the clinical profile and negative impact on prognosis has been well characterised in research on dual diagnosis samples from high income countries, little is known in the low- and middle-income country (LAMIC) context about the prevalence and factors associated with SUDs in patients with SMI, its clinical identification and diagnosis, as well as factors associated with its treatment. Objectives: In part-I of the thesis I investigate the clinical epidemiology of dual diagnosis by determining the prevalence of substance use disorders (SUDs) and its association with various clinical and demographic factors in two datasets, the first dataset containing data from a homogeneous sample of Xhosa South African patients with schizophrenia and the second dataset with data from a clinically more heterogeneous sample of patients with major affective and non-affective psychotic disorders. In part-II of the thesis I determine the psychometric properties of two Xhosa language versions of brief substance screening instruments, the Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST version 3) and the Severity of Dependence Scale (SDS), against a gold standard diagnostic instrument, the Structured Clinical Interview for DSM-IV-TR Axis I disorders (SCID-I for DSM-IV). In part-III of the thesis I examine aspects in the pharmacotherapy of dual diagnosis, firstly the association between methamphetamine use and extra-pyramidal medication side-effects (EPS) in patients treated with antipsychotics, and second in a systematic review, the efficacy of risperidone versus other antipsychotics for people with a dual diagnosis. Methods: This thesis consists of secondary analyses of two datasets (datasets#1 and dataset#2) and a Cochrane systematic review of existing randomised trials. Dataset#1 contains data from case-control study with the original aim of investigating the genomics of schizophrenia in the South African Xhosa population. Dataset#2 contains data collected in a cross-sectional manner from 3 studies; one study that investigating the presentation and psychobiology of psychosis, another which was a pilot randomised controlled trial of a text message treatment partner intervention and a third which was a neuroimaging and electrophysiological study of psychotic disorders. Across dataset #1 and #2, demographic information, clinical variables and psychotic and substance use disorder diagnoses were determined using the SCID-I for DSM-IV. In addition, for dataset #2 (conducted in a multi-cultural and ethnic population) we recorded self-identified ethnicity. For self-identified ethnic groups, the terms “Coloured” “Black” and “Caucasian” and “Other” (Asian), were not intended to reify sociocultural constructs but were instead used to study ongoing health disparities. Psychosocial Axis-IV problems were determined using a checklist from the SCID-I and legal involvement was determined using the legal section of the Addiction Severity Index (ASI). Functioning was determined with the global assessment of function, or GAF scale. The ASSIST and SDS instruments were used in a study based on data from dataset #1 investigating the psychometric properties of these screening tools. In turn, I investigated the relationship between methamphetamine use and medication related extra-pyramidal side effects (EPS) in a heterogeneous sample of patients with major affective and non-affective psychotic disorders (from dataset #2). For this study the Simpson Angus Scale for Parkinsonism (SAS), the Barnes Akathisia Rating Scale (BARS) and the Abnormal Involuntary Movement Scale (AIMS) were used to measure EPS. For the first two objectives, logistic regression modelling was used to determine factors associated with having a cooccurring SUD. For the validation study of the Xhosa language versions of the ASSIST and SDS, I determined the internal consistency, concurrent validity, and discriminant validity of these instruments and compared the sensitivity, specificity and the receiver operating characteristics (ROC) for the ASSIST and SDS. Logistic and ROC regression was used for the comparison of ROC area-under-the-curves for ASSIST versus SDS and for determining the impact of co-variates on ROC respectively. In part III, I determined the association between methamphetamine use and the presence of EPS using logistic regression. Finally, I conducted a Cochrane systematic review of randomised trials after a comprehensive literature search of several databases and duplicate study selection and data extraction. Where possible outcomes were pooled, and meta-analyses conducted using random effects models. Primary outcomes were changes in substance use and mental state. Secondary outcomes included substance craving, subjective-wellbeing, adherence, adverse effects, study retention, quality of life and mortality. Study selection, data extraction and quality appraisals were independently conducted. Random-effects meta-analysis was conducted, and the Cochrane risk of bias and GRADE approach used to assess evidence quality. Results: In both datasets#1 and #2, consisting of a total sample size of N=1420 (dataset#1) and N=248 (dataset#2) we found a high prevalence of lifetime SUDs (47.8% and 55.6%) in patients with schizophrenia and major affective or non-affective psychosis, respectively. In multivariable logistic models younger age, male gender, and legal involvement were significantly associated with co-occurring SUDs. Multiple substances were often used together, and SUDs were significantly correlated with one another. Methamphetamine use disorders were significantly more prevalent in the Western Cape province of South Africa and ethnic differences were also apparent with Coloured participants significantly more likely to use methamphetamine compared to Black participants. In addition, we found significant associations between post-traumatic stress symptoms, anxiety symptoms and suicidality and alcohol use disorders. Inpatient status and higher levels of prior admissions were associated with cannabis and methamphetamine use disorders. In a sample of 351 participants from dataset#1 who completed either the ASSIST (N=190), SDS (N=299), or both (n=138), good internal reliability was obtained for both the ASSIST-TSI (total substance involvement score) (Cronbach α= 0.77) and SDS (Cronbach α=0.80). The ASSIST and SDS demonstrated good concurrent validity (rs= 0.50, p 3 years were significantly more likely to have EPS. We found a significant interaction effect between MA use disorders and standardised antipsychotic dose on the occurrence of EPS (ORadj = 1.01, 95% CI= 1.00-1.01, p=0.042). There were no significant associations with EPS with comorbid alcohol, cannabis, or methaqualone use disorders. In the Cochrane systematic review of randomised controlled trials involving risperidone versus other antipsychotics for dual diagnosis, we identified eight trials containing a total of 1073 participants with SMI and co-occurring SUD. Seven trials contributed useable data to the review. Risperidone was compared to clozapine, olanzapine, perphenazine, quetiapine and ziprasidone. Only one study contained data comparing risperidone with a first-generation antipsychotic (perphenazine). Quality of the included studies varied from low to very low. Outcome data were frequently missing and little, or no data was reported in most studies for craving, subjective-wellbeing, metabolic disturbances, global impression of illness severity, quality of life or mortality. For risperidone versus clozapine we found no clear differences between these two antipsychotics in the reduction of positive psychotic symptoms or reduction in cannabis use, improvement in subjective well-being, numbers discontinuing medication, extrapyramidal side-effects or leaving the study early. Clozapine was associated with lower levels of craving for cannabis. For risperidone versus olanzapine we found no clear differences in the reduction of positive psychotic symptoms, reduction in cannabis use, craving for cannabis, parkinsonism, or leaving the study early. For risperidone versus perphenazine, quetiapine and ziprasidone respectively, we found no clear differences in the number of participants leaving the study early. Conclusion: In the context of a dearth of research into dual diagnosis in LAMIC countries such as South Africa, this thesis contains a large-scale epidemiological investigation into substance use comorbidity in patients with schizophrenia and other psychotic disorders. In addition, for the first time we determine the psychometric properties and validity of the Xhosa language ASSIST and SDS and systematically investigate the relationship between methamphetamine use and extra-pyramidal side effects in people with psychotic disorders treated with antipsychotics. For the first time we also conduct a systematic review of the efficacy of risperidone compared to other antipsychotics for a number of primary and secondary outcomes. Our findings have a number of implications for clinicians and services planners. Firstly, SUDs occur in at least half of the people schizophrenia and other psychotic disorders. Accurate detection of SUDs is possible using brief screening tools such as the ASSIST and SDS. Some populations such a younger male population may need particular attention. Moreover, assessment of patients will need to include current and past legal involvement as well as careful assessment of associated comorbid anxiety, post-traumatic symptomology and suicide risk. In patients with co-occurring methamphetamine use disorders clinicians should regularly assess for the development of EPS and carefully titrate antipsychotic dosage from lower to higher doses to avoid EPS. Currently there is not sufficient high-quality evidence favouring the superiority of risperidone over any other antipsychotic in people with SMI and co-occurring SUDs. Results of ongoing trials are awaited, and future trials need to use consistent methodologies and adhere to CONSORT reporting guidelines.

The complexity of information produced since the 1980's on co-occurring severe mental illness and substance misuse makes it difficult for social workers to grasp the current state of the question. This is a new field of study, and much of the information is incomplete or contradictory. This review examines epidemiological studies carried out in North America. We identify the varied semantic and philosophical approaches to the question of dual diagnoses, and provide an overview of etiological theories, as well as of the theory and practice of treatment for these disorders. Emergent concepts of recovery are also discussed.
Major findings. epidemiological data vary, but all point to a widespread problem. The diversity of meaning and of etiological theories appears to be linked to the heterogeneity of this population. An integrated treatment strategy is the current modality of choice, despite outcomes that are only mildly encouraging; finally, there is consensus among consumers that recovery from a disease is possible even in the absence of a complete cure.
Research limitations and knowledge gaps are to be expected in a new field of study. Additional research is necessary to determine the extent and causes of these comorbidities. Social workers must become knowledgeable in this field and remain abreast of new developments in order to engage in evidenced-based practice. Greater education about comorbidities is necessary, as is an overarching policy response from all levels of government. The principal contribution of this master's thesis to the discipline of social work is to provide a general synthesis of knowledge in a domain that is highly medicalized in the literature.

Background: Preventing injuries among children and young people is a priority in England and worldwide; with injuries a leading cause of death, ill health and disability in children, and resulting in substantial costs to health services and society. Understanding the burden of injuries is important for health service planning and the prioritisation of preventative interventions to those at greatest risk. Despite this, estimating injury burden in England remains a challenge due to fragmented data collection systems and no national surveillance system. The recent linkage of a large primary care research database, the Clinical Practice Research Datalink (CPRD), to hospitalisation and mortality data, offers a new opportunity to study the epidemiology of injuries and provide more complete estimates of injury incidence. Mental illnesses are the commonest morbidity women experience during pregnancy and the postnatal period, and are associated with several child health outcomes. The impact of maternal mental illnesses on the occurrence of childhood injuries is underexplored; with existing studies giving mixed findings, focusing upon depression alone and relying on maternal reporting of injury occurrences. Existing studies suggesting an association between maternal perinatal depression and childhood injuries have not considered the role of ongoing maternal depression after the postnatal period, and whether observed associations could be explained by biases in the reporting of injuries by mothers, or the recording of injuries by clinicians. Methods: Three large routinely-collected datasets from England, the CPRD, Hospital Episode Statistics (HES), and Office for National Statistics (ONS) mortality data, were used to conduct a series of studies. 1. The epidemiology of injuries among children and young people. A cohort of 1,928,681 individuals aged 0-24 years old from England who had linked CPRD, HES and ONS mortality data was used to describe the epidemiology of three common injuries (poisonings, fractures, burns). Time-based algorithms were developed to identify incident injury events, distinguishing between repeat records for the same injury, and those for a new event. Injury incidence rates and adjusted incidence rate ratios (aIRR) were estimated by age, sex, calendar year and socioeconomic deprivation. The recording of injury mechanisms and intent were examined for the three data sources. 2. Maternal mental illnesses during pregnancy and the child’s first five years of life. A cohort of 207,048 mother-child pairs from England who had linked CPRD and HES data, with children born 1998-2013, was used to define episodes of maternal depression and/or anxiety (termed ‘depression/anxiety’) using diagnostic, prescription and hospitalisation records. Incidence rates of maternal depression/anxiety were described over the child’s first five years of life. 3. Maternal perinatal depression and injuries in children aged 0-4 years old. A cohort study of 207,048 mother-child pairs compared incidence rates and adjusted incidence rate ratios of child poisonings, fractures, and burns among children whose mothers had experienced perinatal depression with those who had not. To assess how the association between perinatal depression and child injury was affected by subsequent exposure to maternal depression, adjusted incidence rate ratios were compared for mothers whose depression continued beyond or recurred after the postnatal period, with mothers in whom it did not. Analyses were repeated for a group of serious injuries where injury ascertainment was more likely to be complete. 4. Association between episodes of maternal depression/anxiety and rates of child injuries. Two analyses, a traditional cohort analysis (a between person design) and a self-controlled case series (SCCS) analysis (a within person design where individuals act as their own controls), were used to compare incidence rates of child injuries during episodes of maternal depression/anxiety with periods when mothers had no evidence of depression/anxiety in their medical record. These two methods were compared as they account for confounding by different means. Results: 1. The epidemiology of injuries among children and young people. For the period 2001-2011, incidence rates of poisonings, fractures and burns were 41.9 per 10,000 person-years (PY) (95%CI 41.3-42.5), 185.5 (95%CI 184.6-186.4) and 34.6 (95%CI 34.2-35.0), respectively among the cohort of 0-24 year olds. Of the injury events identified in linked CPRD-HES-ONS mortality data, 18,065 (51%) poisonings, 117,102 (75%) fractures, and 26,276 (91%) burns were only recorded in primary care data (CPRD). Injury mechanism and intent recording was high within hospitalisation and mortality data (80-100%), but low in primary care data (2-4% of burns and fractures). Age patterns of injury incidence varied by injury type, with peaks at age 2 (69.4/10,000 PY) and 18 (76.0/10,000 PY) for poisonings, age 13 for fractures (310.1/10,000 PY) and age 1 for burns (113.1/10,000 PY). Over time, fracture incidence rates increased, whereas poisoning rates increased only among 15-24 year olds and burns incidence reduced. Poisoning and burn incidence rates increased with deprivation, with the steepest socioeconomic gradient between most and least deprived quintiles for poisonings (aIRR 2.20, 95%CI 2.07-2.34). 2. Maternal mental illnesses during pregnancy and the child’s first five years of life. 4,210 (2.0%) mothers had antenatal depression, 20,486 (9.9%) had postnatal depression, and 7,413 (3.6%) had both. Between the child’s birth and fifth birthday, 54,702 (26.4%) children were exposed to one or more episode of maternal depression/anxiety, with incidence rates of maternal depression, depression with anxiety and anxiety alone 6.92/100 PY (95%CI 6.86-6.98), 1.30 (95%CI 1.27-1.33) and 1.83 (95%CI 1.80-1.86), respectively. 3. Maternal perinatal depression and injuries in children aged 0-4 years old. Among 207,048 children, 2,614 poisonings, 6,088 fractures and 4,201 burns occurred during follow-up. Children whose mothers had perinatal depression had higher injury rates than children who were unexposed, with associations strongest for poisonings. Compared to those unexposed, poisoning rates were 74% higher among children exposed to antenatal depression (aIRR 1.74, 95%CI 1.39-2.18), 55% higher for postnatal depression (aIRR 1.55, 95%CI 1.39-1.72) and 89% higher for children exposed to both (aIRR 1.89, 95%CI 1.61-2.23). Children also exposed to maternal depression when aged 1-4 years old tended to have higher poisoning, fracture and burn rates than children only exposed to perinatal depression. Significant associations persisted when analyses were restricted to serious fractures and burns. 4. Association between episodes of maternal depression/anxiety and rates of child injuries. In the traditional cohort analysis, child poisoning rates were increased during episodes of maternal depression (aIRR 1.52, 95%CI 1.31-1.76), depression with anxiety (aIRR 2.30, 95%CI 1.93-2.75) and anxiety alone (aIRR 1.63, 95%CI 1.09-2.43). Similarly, rates of burns (aIRR 1.53, 95%CI 1.29-1.81) and fractures (aIRR 1.24, 95%CI 1.06-1.44) were greatest during episodes of maternal depression with anxiety. No association was seen between maternal depression/anxiety and serious child injuries. The study populations for the SCCS analyses consisted of 2,502, 5,836, 4,051 and 909 children who had experienced a poisoning, fracture, burn or serious injury, respectively. For children who experienced a poisoning or burn, poisoning (aIRR 1.48, 95%CI 1.19-1.85) and burn (aIRR 1.29, 95%CI 1.07-1.55) rates were only increased during periods when the mother had depression compared to periods when the mother had no evidence of depression/anxiety in their medical record. No significant differences in fracture or serious injury rates were seen during depression/anxiety episodes compared to unexposed periods. Conclusion and implications: It is essential to use linked primary care, hospitalisation and mortality data to estimate injury burden, as many injury events are only captured within a single data source. Linked routinely-collected data may offer an affordable mechanism for injury surveillance; although is limited by poor recording of injury mechanism and intent within primary care data.
Differing injury patterns according to age and injury type reflect differences in underlying injury mechanisms, highlighting the importance of tailored preventative interventions across the life course. Inequalities in injury occurrences support the targeting of preventative interventions to those living in the most deprived areas. Future work includes extending this research to other injury types and incorporating emergency department data when this becomes available.

The overarching aim of this dissertation is to use health services research methods to address three problems in behavioral health services. This dissertation seeks to address the knowledge gaps in behavioral health services through the generation of evidence intended to support evidence-based practices (EBP). Previous work has examined epidemiology of behavioral health disorders in the ED, but they have not attempted to examine disorders by the cause of injury. Chapter 2 examines the epidemiology of psychiatric disorders among adults who seek care in the emergency department (ED) by cause of injury. Data from a national hospital discharge survey was analyzed using logistic and multinomial regression. Estimates are given as average marginal effects (AME) to simplify the interpretation and application. Intentionally-caused injury and undetermined cause of injury are significantly associated with psychiatric disorders. Patients with undetermined cause of injury were more likely to be diagnosed with anxiety disorders, depressed mood, and psychoses relative to patients with unintentional injuries Since there are several treatment options for obsessive-compulsive disorder (OCD), including cognitive behavioral therapy (CBT), serotonin reuptake inhibitors (SRIs), and combinations of these, a comparison of treatment effects denominated in dollars is helpful when comparing risks and benefits. Chapter 3 builds on previous randomized control trials of treatments for OCD in children and adolescents by ranks the cost-benefits of first-line treatments. The analysis aggregates treatment effects from published trials in meta-analytic framework and a Monte Carlo simulation of 100,000 hypothetic children and adolescents to derive ranked cost-benefit. Treatments strategies starting with CBT, but not CBT and SRIs concurrently, were the most cost-beneficial. The relationship between cost-sharing and utilization of behavioral health services has been studied in the aggregate, but there has been little work examining the relationship by disorder and treatment modality. The aim of Chapter 4 is to examine the association between cost-sharing and utilization of psychotherapy and adherence to pharmacotherapy among insured adults with OCD. This chapter utilizes the Truven MarketScan Commercial Claims and Encounters dataset to perform zero-inflated negative binomial regression and logistic regression analyses. Increased cost-sharing was significantly, negatively associated with psychotherapy intensity and dose, but not associated with SRI adherence. This dissertation examined three different research questions to address gaps in the behavioral health services research. The findings of these chapters have implications for patients, clinicians, insurers, and policymakers. The results can be used to improve aspects of cost, quality, access, and efficiency of behavioral health services.

Children with chronic physical illness have twice the risk of psychosocial maladjustment as healthy children. One specific aspect of mental functioning is abnormal eating attitudes, hypothesized to be an early stage of an eating disorder. To date, there has been no study of the association of a variety of physical chronic illnesses with a specific psychiatric syndrome in a diagnostically heterogeneous population, comparing chronically ill children with healthy children. This study examined the association between chronic illness and eating attitudes in a population of school children from Western Quebec. A checklist of chronic medical conditions was added to the parent questionnaire in order to determine presence of chronic illness. There were two objectives of this thesis. The first objective was to determine whether chronic illness was associated with eating attitudes in children as measured by the Eating Attitudes Test. The second study objective was to determine whether there was a meaningful group difference in othcr psychometric scores of depression, family functioning and stress between children with a chronic illness and children without a chronic illness. (Abstract shortened by UMI.)