Psychiatric cases in community studies: How important an issue?

02-'-9516 S6 S3DC-0.00 PcrpmonPreuLrd

PSYCHIATRIC CASES IN COMMUNITY STUDIES: HOW IMPORTANT AN ISSUE? GEORGE W. BROWX and T. K. J. CRAIG Department

of Social Policy and Social Science, Royal Holloway of London). I I Bedford Square, London

and Bedford New College (University WCI. England

Abstract-Over the last I5 years the use of standardized clinical-type psychiatric interviews has been extended to the general population and we have a much better understanding of the extent of affective disorder and factors of aetioiogical importance. The surveys have revealed a worrying amount of affective disorder, of much the same order of severity as those treated in out-patient clinics, particularly among working-class women in inner-city areas. Relatively few are seen at any point by psychiatric services although half the conditions at any one point in time are chronic. Despite the increasing interest in this work relatively few studies have Tet been published. The scientific status of the instruments and the

generalizability of the current tindings and some of their implications are discussed.

Psychiatry as a branch of medicine shares its use of disease theory as an approach to the study of abnormality; i.e. the grouping of observed symptoms into patterns or syndromes. not simply in order to classify, but with the aim of linking them with particular aetiological factors and treatments. There is no doubt that the approach has served medicine well. yet for psychiatric disorders, and affective illness in particular, most attempts at aetiological classification have been dogged by controversy. For example, one influential classificatory system has attempted to distinguish the sadness felt as a response to unhappy circumstances and the profound depression characteristic of certain hospitalized patients. Psychiatrists of the nineteenth and early twentieth centuries, largely basing their judgements on observations of in-patients concluded that such a distinction could be made with relative ease and that environmental precipitants among the severely depressed were infrequent [I]. However, more latterly. clinicians have found themselves confronted with a far wider range of psychiatric disorder particularly when working in out-patient clinics which have greatly expanded over the last 30 years. Many more mild depressive states are seen in this setting, and attention increasingly has to be given to syndromes that often lack the more profound symptoms to be found among the in-patient population. However. even among in-patients such symptoms are probably only to be found among a minority and one of the problems has been that disputes about diagnostic issues are often couched in terms of clear-cut and non-overlapping phenomena when in practice. although differences exist. they are partial with a good deal of overlapping. There has been even greater uncertainty about the aetiological role of stress in such conditions and how far any such role should be reflected-in the diagnosis. With one possible exception, that of the identification by the St Louis school of a relatively homogenous but small group of bipolar disorders, no classification has achieved any clear aetiological demarcation of affective disorder [I].

The current edition of the International Classification of Diseases records six categories of affective disorder dealing with response to stress or life events, two of which are characterized by psychotic symptoms and four (including ‘neurotic depression’ and ‘adjustment reactions’) which overlap with each other to an extraordinary degree [3]. To understand the basis of this confusion, one need only recall that existing classificatory systems are largely based on disorders seen within hospital settings. Hospital studies have the dubious advantage of lacking any real pressure to define psychiatric disorder as such. Cases’ are simply those who enter the treatment population. The job of designating them as cases in essence comes earlier and is carried out either by the patients themselves or by some referring agent [4]. Goldberg and Huxley’s recent discussion of pathways to psychiatric care is particularly illuminating about the extent to which milder conditions tend to be ‘filtered out’ by referring agencies and the recognition that the main task of detection and management of psychiatric disorder, both in the United States and the United Kingdom (and undoubtedly elsewhere in Europe), falls on the shoulders of the general practitioner. They estimate that on average no more than half of those attending a general practice surgery who are suffering from a psychiatric disorder are recognized by their doctor as disturbed and thus are even considered for referral [5]. Figure I, reproduced from Goldberg and Huxley, reflects in general terms the relative size of the populations involved in these selective processes. It shows that on average only some I in 14 of those suffering from a psychiatric disorder pass the final filter to out-patient care. Reiger et al. [6] argue that much the same order of probabilities holds for the U.S. The exact probabilities, of course, will depend on the threshold taken for the definition of a case. However. such u-ork is enough to illustrate how unsatisfactory it would be for epidemiological purposes to define a ‘case’ in terms of attendance at a treatment centre. This does not rule out using the level of disturbance commonly met in, say, a psychiatric out-patient clinic as criteria for making such a definition.

GEORGEW. BROWN and T. K. J. CR.AIG

h B C a

= = = =

Consulr ihar doctor dunng year Psychiatncally 111dtmng year (Icrcl I) Idenrlticd by their docror as psych,mically Ret-crrcd to a psychww (level 3)

111(:e:cl 2)

q Do nor pars m m

1st filter (111,but do nor consult) Do nor pass 2nd illrcr (dlness unrecognised by dmor) Do nor pars 3rd filier (nor i&red Io a psychlarris0

Fig. I

SIEASUREME~T

OF SYMF’TOMS

It is often asserted that the best, if not only, appropriate basis for assessing psychiatric disorder is the judgement of an experienced clinician. We believe there is a good deal of truth in this and early surveys when restricted to a small group of clinicians trained in the same tradition had some success-e.g. [7]. The most well known is Essen-Moller’s monumental survey near Lund in Sweden who made a point prevalence study of all 2550 inhabitants in the area. It employed a somewhat idiosyncratic diagnostic classification of mental illness and abnormality and it is perhaps because of this that it has not had a greater impact. By using a small number of psychiatrists trained in the same tradition it had many of the features of more recent enquiries using standardized clinical-type interviews and has produced findings of considerable interest [S, 91. But in spite of a handful of such impressive studies it became clear that everyday clinical judgement was too fragile a foundation on which to proceed and that epidemiological research needed more broadly based instruments. It had been well documented that in everyday practice psychiatrists showed a marked tendency to underdetect symptoms, to construe them differently from patients and to show a disappointingly low level of agreement among themselves [IO-131. In short clinical judgements had to be standardized.

The SADS has more recently been superseded by the Diagnostic Interview Schedule (DIS) a highly structured questionnaire which may possibly minimize error produced by different interwewing styles. It can. unlike the SADS. be used by a lay interviewer.

A number of standardized clinical-type interviews have been developed in the last 20 years using questions aimed to establish the presence of symptoms of a type and severity typically encountered in hospital practice. Three instruments are in common use today: the Present State Examination (PSE) [I-&]. the Schizophrenia and Affective Disorder Schedule (SADS) [I51 and the Clinical Interview Schedule [l6]*. While each uses somewhat different criteria for symptom inclusion, they agree broadly. at a symptomatic level on the range and severity of symptoms to be included. There is no doubt that the! have resulted in improved measures of disorder; and in addition to their generally high inter-rater reliability. share advantages of minimizing any ‘acquiesence set’. It has been suggested that standardized clinical-type interviews are open to the cueing of responses from patients. The systems discussed here minimize this possibility in a number of ways. The rateable items are closely defined; open questioning is used and there is a system of cross checking with associated symptoms. Unlike the Clinical Interview Schedule, the PSE and the SADS, were originally developed with hospital in-patients and tend, if anything, to have high thresholds for inclusion of particular symptoms. It is therefore perhaps in some ways unfortunate that they have been the basis of most population surveys; but on the other hand it is probably useful that any bias would tend to act against the inclusion of ‘normal’ reactions to stressful circumstances. As an example of this. consider a woman, who complains of feeling depressed and tearful, usually for an hour or two each evening on return from work. finds herself busying about the house in an effort to take her mind off the sadness with some limited success and denies being depressed at other times including while at work. Such a ‘symptom’ of depressed mood. though clearly present in a mild degree would not be sufficient to rate on the PSE. Furthermore this would remain so even had she been considered to have other rateable symptoms such as sleep disturbance. On the other hand, a woman who complains of profound and unrelenting grief. who finds she can take her mind off her sorrows only with considerable effort and then only briefly, would probably be rated for depressed mood regardless of the existence of a plausible explanation for her unhappiness. This last qualification is an interesting one. The rating instructions to the PSE allows rejection of certain symptoms on the grounds that they can be seen as understandable reactions to provoking circumstances. In practice, most researchers rate symptoms entirely in terms of judgements of clinical severity. Certainly, for aetiological research, it would be totally unacceptable to make judgements about the appropriateness of the response, not only because this is in practice extremely difficult, but more essentially because of defeating the whole purpose of such research by building into enquiries assumptions incorporating precisely those hypotheses which require empirical testing. Indeed this is in the spirit of the more general formulation of the authors of the PSE. who state that such judgements are really only helpful where environmental problems are obviousI> rrlcial [I?. p. 1421.

Psychiatric cases in community studies ASCERTAI;VMEX

OF CASESESS

Turning to the broader issue of whether a complex of symptoms is enough to justify the classification as a ‘case’, it is essential that a measure should not only distinguish the two extremes of ‘caseness maximally present’ and ‘caseness definitely absent’ but should also reflect something of the transition between these extremes. Although most systems attempt this, it is surprising how often subthreshold disorders are simply discarded from any further consideration. As we noted earlier, instruments such as the PSE already have a tendency to excIude symptoms and, given this, particular care should be taken at the next stage of defining ooerali severity since some ‘subthreshold cases’ may well reflect critica transition states between ‘normal distress’ and ‘definite psychiatric disorder’. It is possible to use the basic PSE symptom scores to reproduce typical syndromes of in-patients and out-patients and to derive diagnoses such as those of the International Classification of Diseases by means of the Index of Definition (ID)--CATEGO computer system of analysis, which utilizes a complex system of prior rules reflected in the computer program [14]. It is easy to apply with minimal training, and will produce totally consistent results, but only in terms of the range and patterning of symptoms anticipated in the original design of the computer programme. A second approach permits almost equally consistent results but requires considerably more time in training and supervision to achieve. This is the method developed at Bedford College in which symptoms on the PSE are collected for I, 3 and 12 month periods and those considered by a panel of raters to have experienced a definite psychiatric syndrome are classified as cases for these periods, and those who had had symptoms that are not sufficiently typical, frequent or intense enough to be rated as cases are classified as ‘borderline cases’*. There are also women in the general population with psychiatric symptoms such as fatigue, minor sleep disorder and nervous tension which are not sufficient to warrant even a ‘borderline case’ rating. Essential to the whole procedure has been the development of reference examples of cases and borderline cases in each diagnostic group. As a quick guide the following checklist has been shown statistically to underlie the clinical criteria for depression that we developed [ 171. For the diagnosis of a case of depression both A and B must be present: (A) Depressed mood. (B) Four or more of the following symptoms: hopelessnesss, suicidal ideas or actions, weight loss, early waking, delayed sleep, poor concentration, neglect due to brooding, loss of interest, selfdepreciation and anergia. In practice, many other symptoms covered by the PSE were also present. *The term ‘borderline case’ is used throughout

this review to refer to conditions which in the Bedford College diagnostic system fall short of definite cases. and does not imply the serious personality disorder designated in certain clinical diagnostic systems.

175

The two criteria for the diagnosis of a borderline case of depression were: (A) Depressed mood. (B) Between 1 and 3 of the symptoms listed above. Lay interviewers were used: all were trained by psychiatrists who had been associated with the development of the PSE. Studies of inter-rater reliability showed that non-medical interviewers could reach the high standards of reliability achieved by psychiatrically trained interviewers [18. 19). One strength of the approach is that each symptom is exposed to consensus judgement of a team of raters and that major syndromes are treated nonhierarchically. This permits an anxiety state to be rated separately from a depressive disorder and allows a subject to be characterized by separate diagnoses at different levels of severity--s.g. case depression: borderline case anxiety [20, 21). In the final analysis, there is a good deal to be gained from using computerized decision matrices; the danger is that these will not remain open to re-examination and modification in the light of new knowledge and experience. Our judgement is that at present there is much to be said for working Lvith the more flexible Bedford College system, while encouraging the parallel use and development of computerbased approaches. Preparatory to discussing the findings of recent aetiological studies it might prove useful to illustrate the way in which these two diagnostic systems cope with a threshold example. A woman of 56 moved in to a small terrace 1 year before interkietv. Her daughter visits her weekly but otherwise she has no friends or social contacts which she explains as due to her lacking enough confidence to go out to meet people at a local social club. At interview she complains of feeling depressed and generally ‘fed-up’. She says there is little that can cheer her up but admits that there are odd days when she is less miserable. In addition to feeling depressed she complains of being fidgety and excessively tired which she blames partly on poor sleep. She regularly takes two or more hours to fall asleep in spite of hypnotic medication, and says she has difficulty thinking as her mind feels ‘muzzy’ all the time. She has impaired concentration although she can read a short newspaper article if she ‘really tries’ and claims to have lost interest in her former social and recreational activities. Although always pleased to see her daughter, she says she feels generally irritable and frequently ‘takes this out on her’ which leads to quarrels. PSE symptoms rated were: Tiredness-l Restlessness-l Inefficient thinking--l *Impaired concentration--l Depressed mood- I *Loss of interest-l Self confidence- I *Delayed sleep-2 Jrritability-2 She was considered as having ‘borderline depression’ according to Bedford College caseness criterion. This decision was made on the grounds of the

176

GEORGE

W.

BROU.Nand T. K. J. CR.UC

fluctuating nature of her symptoms and the fact that though quite a number of non-specific symptoms were present, there were in addition to depressed mood only 3 ‘core’ symptoms of depression which have been marked by an asterisk. Finally. many of the PSE sytnproms themselves were somewhat threshold examples: that is, due to the fluctuating nature of the disorder they only just qualified for inclusion. By the ID-CATEGO diagnostic system, by contrast her symptoms attain the level of a case and as such CATEGO classifies her to a tentative International Classification of Disease diagnosis of neurotic depression. Clearly it is not a matter of either approach being correct in any absolute sense, though as noted earlier, clinical judgements on caseness do have the advantage of utilizing the descriptive material surrounding each symptom. In a recently completed though as yet unpublished longitudinal investigation, such pure depressive borderline case conditions had on average 3 of the core depressive symptoms listed earlier. Cases of depression were on the whole a good deal more disturbed. If depressed mood is excluded, they exhibited a mean of 5.5 out of a possible 10 core symptoms of depression and many non-depressive symptoms were usually present as well. The alternative system of case identification which might be expected to give comparable results to those obtained using the PSE, is the Schizophrenia and Affective Disorder Schedule (SADS) and its accompanying diagnostic system, the Research Diagnostic Criteria (RDC). As with the PSE-CATEGO systems, ‘diagnosis’ is descriptive rather than ‘aetiological’ and relies on syndromal patterns to derive diagnoses. Hoaever, despite these superficial similarities, there is little likelihood that both will identify cases in common because of the different definitions of vvhat are acceptable levels of severity and duration of symptoms for inclusion, and the different time-base used for each interview. One recent study in Edinburgh has examined the three diagnostic systems (ID-CATEGO, RDC and Bedford College caseness) in popular usage by using a modified interview which contained all the items of the shortened version of the PSE together with those items of the SADS necessary to make an RDC diagnosis [22]. Results indicate that though the RDC and CATEGO identify approximately similar casetress rates in a general population sample, they tend to show quite marked discrepancies about which individuals are counted as cases. .4ll but one of the Bedford College cases were CATEGO cases and all were RDC cases [22]. The Bedford College case rate was lower than either the RDC or CATEGO rates. This would be expected as it uses a more restricted set of symptoms in rating caseness and is nonhierarchical in respect to depression and anxiety. It is apparent from these and other studies that the threshold for ‘caseness’ varies somewhat between research centres-depending on the diagnostic system used. There are important differences in the definitions of symptoms. of time covered. and finally in assumptions about the hierarchical nature of psychiatric symptoms. The final stage of CXTEGO. for example, is broadly hierarchical with the diagnosis of anxiety commonly being subsumed under de-

pression when both syndromes are present. This is the orthodox approach of hospital practice. but there are no obvious reasons why this should be upheld. It is, as in the Bedford College system. possible to classify subjects with mixed affective states by characterizing them in terms of diagnostic categories at different caseness lerels. So, for example, one patient might be described as a case of depression and a case of anxiety while another with only minor anxiety symptoms be classed as a case depression: borderline case anxiety. Such a non-hierarchical approach may lead to important advances in knowledge of aetiology. One recent report, for example, suggests that different types of severe event precede the onset of depressive and anxiety cases; those with depression experiencing more severe ‘loss’ events while those with anxiety states more ‘danger’ events-i.e. events carrying the implication that some further extremely unpleasant even might still occur as a result of the severe event provoking the disorder. Of particular interest is that mixed cases of depression and anxiety tend to have experienced both aspects either in the same or in different events [23a]. Apart from such advances in aetiological knowledge, there is a more mundane argument for a non-hierarchical approach. Separately labelling anxiety and depression obviates the need to categorize cases artificially as belonging either entirely to one category or the other; this might well have helped in the Edinburgh population study to bring the caseness diagnoses of the PSE-CATEGO and the SADS-RDC closer together [22]. AETIOLOGlChL STUDIES IN LOSDON AXD THE OUTER HEBRIDES Caseness,

social class and demographic

characteristics

The PSE was applied to psychiatric in-patient and out-patient populations in 1969, taking a sample of women between the ages of 18 and 65, living in Camberwell in South London, and a sample from the same general population in 1970 [24.25] and to a second Camberwell sample in 1974 [19.20]. Studies of two rural populations in the Outer Hebrides followed in 1975 and 1976 in which the same procedures for data collection were employed [2l, 26.271. In addition to rating overall severity and diagnosis the Bedford College approach added to the PSE a method of dating onset. Timing in relationship to putative aetiological factors clearly is critical to any test of their aetiological role. Although it is not an easy task, particularly when certain key symptoms are no longer present at interview, reports are obtained from the women of their symptoms throughout the 12 months. These accounts for the most part have proved to be so confident and detailed that they give the lie to the notion that people’s memories are too vague to date onset. While detail and confidence alone are no guide to validity, a series of interviews with the relatives of depressed patients produced an acceptable level of agreement between relative and patient accounts [20. 351. In what follows we will concentrate on conditions at the caseness level about whose retrospective reporting we have the greatest confidence. Prevalence of case and borderline case conditions in urban Camberwell and rural Outer Hebrides are

Psychiatric cases in community studies Table I. Percentage of homen in Cambcruell and in the Ourcr Hebrides idenutied as cases and borderline caSeS of aRecrive dsorder m the I-year pertod before interview (A) Owrali Camberwell (n = 458) (“A

Outer Hebrides (n = 355) (” .) II 19

17 18

Case Borderline case

(B) BI, socia( class Camberwell Middle class (n =4’8’ 0 Case Borderhne case

8 I7

Working class (n = X0) (“b) 24 18

Outer Hebndes

Middle C1E.S (n = I IO) (“,I

Workiq class (n = 17-t) (“A

I5 I6

13 20

shown in Table 1. The two populations do not differ greatly in overall rates of disorder in the year before interview, but do in the relationship of these rates to social class [28]. In the Camberwell sample, workingclass women have a much greater rate of affective disorder but there is no class difference in the Outer Hebrides. Most of the disorder in both populations was of a depressive nature. ‘Borderline cases’ do not differ in prevalence by class in Camberwell or the Hebrides. In both urban and rural populations, approximately half of the women who were considered cases had had an onset during the year before interview and half were chronic. All but one of the onset cases were of depression. Chronic conditions included other diagnoses, especially of anxiety, although depression was still much the most common syndrome. However, although social class in Camberwell relates very highly to overall caseness, it has different implications for onset and chronic conditions. Particularly notable is the fact that the risk of developing depression in the year before interview was greater only among working-class women with a child living at home. By contrast, prevalence of chronic caseness was greater for working-class women whether or not they had a child at home [20, p. 1531. Other population studies have on the whole found that in urban setting there is a strong relationship between prevalence of psychiatric disorder and class position. Two recent studies in the U.S. using questionnaires have shown sizeable class differences [29,30]. The first population survey in North America using the SADS-RDC has also shown differences in depression with higher rates of unipolar depression among working-class groups [3 I]. The clinical-type interviews have been more commonly employed in Great Britain, and they also show much higher working-class rates [32-351. Particularly significant are three recent large scale enquiries using standardised clinical interviews. One in Edinburgh of 576 women broke new ground by using the PSE and the SADS and employing various methods of dealing with severity and diagnosis [22,36]. They confirm that there are large social class differences at a ‘case’ level: using the PSE-ID-CATEGO system the relative risk is 2.4; for the SADS-RDC it is 2.1 and for Bedford College caseness 3. I. They also confirm that there is no class difference in the prevalence of Bedford College borderline cases. Bebbington and his

ii7

colleagues at the Institute of Psychiatry in London [37] interviewed 151 men and 197 women living in Camberwell using the PSE and ID-CATEGO system of diagnosis. They confirmed the findings of many previous surveys that affective disorders were less common among men than women (6”: vs l5gJ and on present evidence it seems safe to conclude that in urban populations at least rates of affective disorder will be twice as high among women [38]. However. it should not be too readily assumed that there is a greater overall rate of psychiatric disorder among women. While women have been consistentlv shown to have more neurotic and psychosomatic disorders. men appear to have disproportionately higher numbers with addictive diagnoses. Disturbed women may be easier to contact in population surveys as they tend to be more often a part of a family unit or at least living in a conventional place of residence. In so far as men with psychiatric disorder are less locked into a family mode of living-and more often, say, part of a drifting or prison populationthen their rate of disorder may be underestimated by conventional sampling. In this same survey by Bebbington et al., a large and statistically significant social-class difference occurred for men (47,: for ‘middle’ and 24% for ‘working class’), but the difference for women did not reach statistical significance (13% vs 21%). Given the widespread support for class differences in a variety of enquiries too much should be made of this lack of significance of the result for women. Surtees et al. suggest that it may be due to the fact that the research staff re-visited many of the women originally seen by the agency interviewers and the somewhat complex caseweighting procedure employed; but it is probably enough to note that the size of the sample of women is relatively small and that the differences for women would reach statistical significance with the sample size of the original Camberwell survey. In general, therefore, there is impressive evidence for both urban and rural populations that certain sub-groups are at greatly increased risk for depressive disorder (and probably also for less frequent anxiety states). Rates of depression are probably lower in rural populations although, as in the Hebrides, there may well be marked differences within such populations. The original Camberwell survey and the recent Edinburgh enquiry also agree on the far greater rates of disorder found among the divorced, widowed or separated (in Camberwell the relative risk comparing this group with married women was 2.2 and in Edinburgh 2.7). In a recent as yet unpublished prospective enquiry on a random sample of some 400 largely working-class women with children at home living in the inner London borough of Islington the rate of caseness and borderline caseness approximates fairly closely to that obtained among workingclass women in the Camber-well sample. During the year at least 1 in 5 of the women suffered from an affective disorder at a caseness level. Prevalence among ‘single parents’ who formed approximately I in 4 of the total sample of women was particularly high, reaching the alarming rate of over 4 in 10. These findings concerning marital status are consistent with most prior research [39-42].

GEORGE

W.

Fio=. 2. Rate of events per 100 women

BROWS

and T. K. J.

in Camberwell

Demographic factors and aetiological agents A major component of the aetiological model developed in the Camberwell research is the power of a particular type of life event to provoke.onset of depression. All types of event included in the study were defined in detail before the research began and were included because they were considered likely to arouse significant positive or negative emotion in most people. In the research itself substantial background information was collected and each event then characterised in terms of a number of contextual scales. That of long-term threat, based on the likely threat of the event about a week after it occurred, proved to be critical. Raters were allowed to take account of everything known about a particular woman except her psychiatric condition and her personal reaction to the event: they rated the degree of threat an average woman would have been judged likely to feel, given that particular biography and situation. Only the most threatening events on the long-term threat scale, termed secere events, provoked onset of depression in either population. They formed only about 1 in 6 of the total events recorded for women in Camberwell (and about the same proportion in the Hebrides). Less severely threatening events showed no association with onset. Figure 2 shows the frequency of all kinds of event in the two populations. The terms ‘younger’ and ‘older’ refer to those without children at home who are under and over 35 years of age. Those with a ‘child at home can be any age between I8 and 65, although most were under 45. Although in both populations there is a major fall in the frequency of all life events with life stage, this does not occur among the small subgroup of severely threatening events, the only type of event capable of provoking onset. Figure 2 also makes clear that the frequency of

CRAIG

and Lewis by severity

of threat

and lif+stage.

all types of event, including that of severe events, is much lower in the rural population [27]. Severe events were the major component ofprocoking agents, the first factor in the aetiological model developed in the Camberwell research. The importance of events of this general order of severity had been established by Paykel et al. in New Haven, and the critical role of ‘severe’ events has been confirmed in a number of subsequent studies (e.g. [43-49]). Certain ongoing difficulties such as poor housing were also capable of producing depression, but not with the same frequency as severe events, and have been included with severe events as provoking agents in the model. They were all markedly unpleasant, had lasted at least 2 years and did not involve health problems. As with severe events, they were less common in the Hebrides than in Camberwell. When such severe events and major difficulties are considered together, the large majority of instances of onset of caseness of depression in the year in both populations were preceded by a provoking agent. However, just as a well-established carcinogen does not always lead to cancer, such an agent does not always bring about depression. Only about 1 in 5 women experiencing one in the year of the study developed depression. Therefore, although provoking agents largely determine whether a woman will develop caseness of depression, they do not tell us who will break down among those with a severe event or major difficulty. This is the function of the second factor of the model, which deals with ongoing vulnerability. Vulnerability factors and depression Lack of an intimate, husband or boyfriend

confiding relationship appeared to make

with a women

cases in community studies

Psychiatric

179

Table 2. Onset caseness depression. intimacy wth husband and presence of a severe event or major difficulty Provoking agent

So provoking

NO

intmxicy (“,)

Intimacy (9;)

Srricr Replicorron of Combernell Sererr ewnrs or major difficu1f.t Brov+n and Harris 1201 (Cambw.+ell) Campbell [XI] (Oxford) Cope [jl] (Oxford) Brow” and Prude (27) (Leuls, Bebbl”g:on r! al. [52] (Camberwll) Parry [491 (Sheffield) Finlay-Jones (Persoul communication) (Regents Park area. London)

agent

NO

intimacy (“,)

Intlmaq (“,J

Suf-ve~

(a]

(b) Srrrrz rrrnfs onlj costsllo [‘T] (Calgs~) MartI” [Idi’ (Manchester) Total

32

(24 76)

10

(9,‘88)

P < 0.001

3

(? 62)

I

(2 193)

NS

50

(8 16)

13

(2, IS)

P < 0.05

9

(I II)

0

(0 29)

NS

-10

(4 IO)

13

(1;s)

NS

17

(16)

7

(I 15)

NS

36

(8 22)

lj

(5’33)

NS

j

(2 10)

/

(I 92)

NS

I2

(8,37)

24

(5121)

NS

II

(5 451

6

(3 49)

SS

31

W26)

10

(5149)

P < 0.05

IO

(Ll9)

5

(5 98)

NS

4s

(24,53)

17

(4123)

P < 0.05

8

(3136)

3

(1,391

NS

(4 561

5

(I4 19:)

NS

(2,5)

4

(2 1')

0.01

(??,280)

3

(29,Sjlt

I2

(6,j2)

NS

(2 74)

NS

j7

(8 14)

21

(5j24)

P <0.05

7

73

(8.11)

14

(2i 14)

P
40

37

(100,268)

I4

Ciorel,v R&red Paykel e, ‘I/. [U]t (South London) Murphy [U]: (North London)

(381275) -

8

-

Studier

82

(9 II)

24

(8134)

3s

(6.17)

I1

(10190)

P
14

(1’7)

0

(O!l9)

3

‘A stud: of d serges of women covering a pregnancy and a birth in every instance. +Study of post partum women. One or more undesirable events and poor communication with husband. :Elderly umple of both sexes. Severe event or major difficulty. Low intimacy = no confiding with anyone. i.e. not only husband

more vulnerable to the effects of provoking agents. For the women who had had a provoking agent and who were not already depressed, lack of such a tie was associated with a greatly increased risk. Furthermore. for those without a provoking agent, lack of intimacy was not associated with an increased risk of depression and it is this characteristic that was used to define rulnerability factors. By and large women do not develop depression when they have only the vulnerability factor; risk is particularly increased when provoking agent and vulnerability factor occur together. although a provoking agent occurring alone does increase risk. This finding concerning lack of intimacy has now been replicated in seven studies using the Bedford College Life Events and Difficulties Schedule (LEDS), including the Hebrides [47-511, and only one study has failed to show the relationship [52]. It has also been found to hold in a closely related study of postpartum women [44] and in an elderly sample. although here lack of confiding with anyone was relevant [45]. Table 2 gives details. Intimacy is a soft measure, at least in a crosssectional survey and we cannot altogether rule out some contribution from bias in reporting. We therefore looked for harder indicators of vulnerability. When considered together, three indicators in Camberwell gave much the same results as intimacy. They u’ere having 3 or more children under 14 years of age living at home, lacking employment away from home and loss of a mother before the age of Il. However. it should be noted that employment had an influence only when at least one other vulnerability factor was present. In the Hebrides only intimacy and

3 or more children under 14 at home clearly acted as vulnerability factors and the intimacy result has been the one most often replicated. However, since indicators such as 3 or more children under l-1 must be somewhat distant from the actual factors of importance, such inconsistency is not surprising-it is, for example, highly likely that lack of employment ‘means’ something else for many women in the Hebrides when compared with their urban counterparts. Research needs to be extended to prospective enquiries with measures reflecting more closely factors considered of theoretical importance. (For example, we have argued that low ongoing self-esteem is a feature of all of the vulnerability factors.) Meanwhile a good prima facie case has been made for the role of vulnerability factors and we will henceforth in this review take their likely importance seriously. The aetiological model as a whole explains most of the social class differences in Camberwell in risk of developing depression. The most straightforward way to illustrate this is to deal with those women experiencing at least one severe event. Class differences were restricted to severe events and even this difference confined to women with a child at home. Thirty-four per cent of working-class and 22”,/, of middle-class women with a child at home had at least one such event. Moreover it was only women with a child at home that showed such a class difference in risk. Only a subset of severe events showed clear class differences: crises concerning finance, housing, husband and child (excluding crises concerning health). Major difficulties broadly paralleled these results.

180

GEORGE W. BROWNand T. K. J. CRUG

However. although provoking agents preceded almost all onsets of depression and were more common among working-class women with children at home, they explained only a modest part of the class difference in risk of depression*. The reason is that the impact of provoking agents is overshadowed by the greater likelihood that uorking-class women experience one or more of the vulnerability factors. Vulnerability factors also help to explain another of the anomalies discussed earlier, the lack of a class difference in the prevalence of borderline case conditions The reason for this seems to be that middleclass women. who are on the whole less vulnerable, tend to develop a borderline case rather than a case condition after a provoking agent. The aetiological model developed in Camberwell explains one further result concerning social class. Although class itself did not relate to prevalence of depression in the Hebrides. a measure of social integration based upon two indicators of a traditional way of life. living on a small farm and churchgoing, was highly related. The most integrated had a much lower prevalence. This appeared to be due in considerable part to the fact that the integration, but not social class, was related both to the rate of provoking agents and to vulnerability factors [27]. Of course. this aetiological model suggests that changes in rates of disorder would be expected to occur with secular changes, say, in rates of unemployment or divorce, and the increase in recent years in the number of single parents in the U.K. is the kind of change that needs to be closely examined. A 25 vear follow-up of the 1946 Lund cohort in Sweden showed that half of the population had moved, the majority to urban areas, and the area itself had been urbanized. Today only 1 in 10 are connected with farming. One notable finding is that for both men and women there had been an increase in incidence of depression during each of the 5 year periods within the 25 years-risk overall had more than doubled. There was a particularly surprising ten-fold increase of depressive disorder with severe or medium impairment among men in their twenties and thirties. DISEASE AND DISTRESS The epidemiologic studies we have reviewed using definitions of stmptoms based on experience with in-patient populations, have clearly demonstrated that community cases exhibit types and severity of symptoms generally similar to those of out-patients. Psychiatric in-patients do seem to differ on two counts: (a) Their disorders appear on the whole to be more severe (i.e. to have more symptoms or to have these symptoms in a more pronounced form).

(b) They more often include symptoms onlv rarely encountered in the community case (particularly psychotic symptoms). In short, once the threshold for inclusion as a case has been passed. there may be a qualitative as well as quantitative difference between community cases and many hospital in-patients. Much of the difference reported between inpatients and community cases is most readily explained by processes of selection of the kind reviewed earlier in which general practitioners selectivelv refer and hospital psychiatrists selectively adm;t the more severe cases. those involving a suicidal gesture, or those with the delusional ideation or hallucinations. Furthermore. selection factors may well influence the link between disorder and .aetiological agent. For example, if one of the factors influencing a general practitioner’s decision to refer a patient to specialist care is how able the practitioner feels to cope with the disorder and. if this decision is influenced by how ‘understandable’ the depression is in terms of the impact of the environment. patients admitted to care will have conditions with a seemingly lower association with stress. Despite this possibility studies of depressed psychiatric patienrs have shown remarkable agreement about the importance of the same provoking agents that play a role in the general population. Table 3 reviews some recent studies. All have used interviewer-based measures: again only the study by Bebbington et al. is an exception and there is good reason to believe this is largely due to failure to replicate the procedures employed in the original Camberwell study of psychiatric patients [53]. The role of provoking agents is apparently somewhat less important in patient populations but given the fact that much the same results concerning life events and difficulties have been obtained for ‘neurotic’ and ‘psychotic’ depressed patients, it would be highly misleading to suggest on present evidence that the critical role of psychosocial factors is basically different among patients and non-patients [20,54-621. In short there is now good evidence to suggest that life stress plays a major aetiologic role in the onset and course of all depressive disorders with the possible exception of certain rather rare bipolar conditions which have so far not been systematically investigated. This is of course not to rule out other aetiologic factors-there is, for example, no reason why biological predisposition should not increase the chance of a major depression after stress. Indeed, the aetiology of affective disorder is, on the basis of present evidence, almost certainly multifactorial. None the less it is now essential for the role of psychosocial factors to be carefully assessed in any such comparisons. IXIPLIC.ATIOZSFOR TREATMEST

*Ei_eht Per cent (3 36) of middle-class women who experienced a provoking agent and who had a child at home developed depression, compared to 31% (21/67) of uorking-class women. For those without a provoking agent risk was only I”/, in both Sroups (l/80) and (l/68) respectively.

If the reader reflects on the results reviewed suggesting that in some working-class populations in inner-city areas 1 in IO women with a child at home suffer a chronic affective disorder at a ‘case’ level, and a further 1 in IO suffer the onser of such conditions during any one year, then the magnitude of the

IYI

studies

Psychiatric cases in community

Table 3. Summarv of recent studies of life ewnts and onset of deorewon

Proportion with

among osvchlatric oatients

at

least one event Sumber of Comparison Comparison SOUCC

Paykcl er al. [5-I] (Sew Haven) Brown and Harris [?O] (London) Barretr [55] (Boston) Glassner et al. [56]* (New York) Fava et al. (571 (Padua) Benjaminsen [58] (Odense. Denmark) Vadher and Ndetei [59] (Nairobt) Bebbington el al. [37]t (London)

Patients

group

IS5

Patients (“A

group (“2 17 19

I I4

IS5 382

I30 25 40 89

25 40 -

44 61 58 56 73 63

30 45

40 257

67 18

16 30

8 IO

Penod corered I? 8 6 I2 6 6

months months months months months months

12 months 3 months

T>pe of event Undesmable Severe threat Undesxable Major role loss Uncontrollable Severe loss Severe threat Marked and moderate threat -independent events

l.ManicAepressive. bipolar sample. tlncludes some anxiety states.

facing therapeutic organizations becomes apparent. It is true that the majority of onset cases will resolve within the year and many between 3-6 months [63,64], and we have seen that the remarkably high rates in inner city populations probably does not apply to all working-class populations. But such comfort should not be taken too far. An overall rate of caseness of l49b for a 12-month period in the isolated and apparently protected population of the Outer Hebrides is high by any standard and, it will be remembered, it was particularly so among the least integrated women. Moreover. of course, it is not only a matter of the individual with symptoms. The impact of a mother’s depression on her children can be considerable. One consequence that can be given some numerical basis is that a marked rise in the number of serious accidents occurring to children both inside and outside the home occurs after the onset of depression in their mother either as a case or a borderline case level of severity [65]. This is not to say all ‘cases’ let alone ‘borderline cases’ require treatment in the conventional sense, or that psychiatrists should be even ideally involved. However, psychiatrists certainly have the responsibility to consider as a profession the problems that arise from the kind of statistics we have outlined and to become involved in programmes to tackle disorder at its roots-in the community. In thinking and practice the developments in America, following the 1963 Mental Health Services Act, of Community Health Centres to serve the needs of particular populations has probably come nearest to grappling with these problems. Schulberg and Killilea [66] have recently published an important review of the movement which owed much to the pioneering theories of crisis intervention of Gerald Caplan [67,68]. Not surprisingly. give the novelty of this approach to psychiatric disorder and its management and the threat that such programmes appeared to pose to traditional psychiatry, there was.always stiff resistance to its introduction and funding. Yet, on the whole, this ‘population ideology’ appears to have increased in popularity, particularly amongst younger psychiatrists and in the allied professions of clinical psychology and social work. It is ironic therefore that in the 1980’s there should be a maior problem

reduction in the political popularity and funding of these programmes of community care. This is partially the consequence of political changes in the U.S., partially the continued pressure from establishment psychiatrists, but, also the consequence of the relative failure of the approach in metropolitan areas where the choice of artificially delineated ‘catchment area’ was probably mistaken and would be better replaced by centres based more on neighbourhood health centres. In addition. the relative ignorance of the epidemiology of relevant conditions and the paucity of sound evaluation research have all contributed to what some see as a current temporary decline [69]. In Europe, the development of such service has continued, though at a very much slower rate. It is clear from a recent review of crisis centres and other community-based emergency facilities that they are almost certainly serving an important role in the management of psychiatric disorder and reducing the need for protracted in-patient care [70]. In general terms, such development is likely to depend in the future somewhat more on careful aetiological and evaluative research and the acceptance by all concerned that this is still a young field of endeavour which may have to undergo considerable local modifications to achieve the very real gains offered by the theoretical stance. How much of the necessary activity can remain within the traditional one-to-one therapist-patient context of psychiatric services will obviously be influenced not only by such research but the power of current interests balanced by the real practical constraints of the sobering numbers involved. REFERENCES Griesinger W. Die Pathologic and Therapie der psychischen Krankheiren, 2nd edition. Braunschweig. Wreden. 1861. Translated as Menral Pathology and Therapeutics (Edited by Robertson C. L. and Rutherford J.). New Syndenham Society. London, 1867. Kendell R. E. The classification of depressions: a review of contemporary confusion. Br. J. Psychiar. 129, 15-28, 1976. World Health Organisation. Glossary of Menra/ Disorders and Guide 10 their Classification for Cie in Conjunction with the International Classification of Diseases. WHO, Geneva, 1978.

ISI 1

5 6 _

Y

9 IO.

II. 12.

13.

I-1.

15.

16.

17.

IS.

19.

‘0.

21.

GEORGE W. BROWN and T. K. J. CRAIG Dohrenwend B. P. and Dohrenwend B. S. Social Srarus and Prrcholorical Disorder.. .A Causal Inauirv. Wilev. ‘ New York. 1969. Goldberg D. and Huxley P. .Wenral Illness in rhe Community. Tavistock, London. 1980. Regier D.. Goldberg I. and Taube C. The defacro U.S. mental health services system: a public health perspective. Archs gen. Ps.vchiar. 35, 685-693. 1978. Larsson T. and Sjogren T. A methodological. psychiatric and statistical study of a large Swedish rural population. .-Lcra psychiar. neural. stand. Suppl. 89. 1954. Essen-Moller E. and Hagnell 0. The frequency and risk of depression within a rural population group in Scania. Acta psychiat. stand. 37, Suppl. 162. 28, 1961. Hagnell 0. A Prospective Study of rhe Incidence of Menfal Disorder. Scandinavian University Books. 1966. Kreitman N.. Sainsbury P.. IMorrisey J., Towers J. and Scrivener J. The reliability of psychiatric assessment: an analysis. J. menr. Sri. 107, 889-908, 1961. Kendell R. E. The Role of Diagnosis in Psychiatry. Blackwell, Oxford, 1975. Conover D. and Climent C. Explanations of bias in psychiatric case finding instruments. J. Hlth sot. Behac. 17, 62-69. 1976. Leff J. P. Psychiatrists versus patients concepts of unpleasant emotions. Br. J. Psychiat. 133, 306313, 1978. Wing J. K., Cooper J. E. and Sartorius N. The Measwemenl and CiassiJicarion of Psychiatric Symptoms: An Instruction Manual for rhe Present State Examination and CATEGO Programme. Cambridge University Press, London. 1974. Spitzer R. L., Endicott J. and Robins E. Research diagnostic criteria: rationale and reliability. Archs gen. Psychiat. 35, 773-52, 1978. Goldberg D. P., Cooper B.. Eastwood R. R.. Kedward H. B. and Shepherd M. A standardised psychiatric interview for use in community surveys. Br. J. prec. Sot. .C/ed. 24, 18-23, 1970. Finlay-Jones R.. Brown G. W., Duncan-Jones P., Harris T., Murphy E. and Prudo R. Depression and anxiety in the community. Psychol. Med. 10, 445-454, 1980. Cooper J. E., Copeland J. R. M., Brown G. W., Harris T. and Gourley 4. J. Further studies on interviewer training and inter-rater reliability of the Present State Examination (P.S.E.). Psvchol. Med. 7. 517-523. 1977. Wing J. K., Nixon J. MI. Mann S. A. and Leff J. P. Reliability of the PSE (ninth edition) used in a population study. Psychol. Med. 7, 506-516, 1977. Brown G. W. and Harris T. Social Origins of Depression: .d Srudy of Psychiatric Disorder in Women. Tavistock, London, 1978. Prudo R., Brown G. W., Harris T. and Dowland J. Psychiatric disorder in a rural and an urban population-2 Sensitivity to loss, Psychol. Med. 11, 601-616, 1981. Dean C., Surtees P. G. and Sashidharan S. P. Comparison of research diagnostic systems in an Edinburgh community sample. Br. J. Psychiar. 142, 243-256, 1983. Finlay-Jones R. and Brown G. W. Types of stressful life event and the onset of anxiety and depressive disorders. Ps,whol. Med. 11, 803-815. 1981. Brown G. W., Sklair F.. Harris T. and Birley J. L. T. Life events and psychiatric disorders-l. Some methodological issues: Psychoi. Med. 3, I, 1973. Brown G. W.. Harris T., Peto J. and Sklair F. Life events and psychiatric disorders-2. Nature of causal link. Psychol. .Cled. 3, 159-176. 1973. Brown G. W., Davidson S.. Harris T., Maclean U., Pollock S. and Prudo R. Psychiatric disorder in London and North Uist. Sot. Sci. ‘Med. 11, 366377. 1977.

27 Brown G. VV. and Prudo R. Psychiatric disorder in a rural and an urban population-l r\etiology of depression. Psuhoi. Med. 11. 581-599. 1981. 28 Brown G. W. and Harris T. Social class and atfective disorder. In Culrure anti PsJchoparhologF (Edited by Al-lssa I.). University Park Press. Baltimore, 1982. 29 Warheit G.. Holzcr C. III. and Schwab J. r\n analysis of social class and rscial differences in depressive symptom-aetiology: a community study. J. Hlth SOC. Behac. 4, 921-999. 1973. G. W. and Hrlsing K. J. Symptoms of 30 Comstock depression in two communities. Ps.vchol. .Lled. 6, 551-563. 1976. 31 Weissman 41. M. and Myers J. K. Affective.disorders in a United States urban community: the use of research diagnostic criteria in an epidemiological survey. Archs gen. Psychiat. 35, l304-I31 I. 1978. 32. Richman N. The effects of housing on pre-school children and their mothers. Der. .Ved. Child .Veurol. 16, 53-58, 1971. 33 Richman S. Depression in mothers of preschool children. J. Child Ps~chol. Psychiar. 17, 75-78. 1976. 41. and Quinton D. Psychiatric disorder34. Rutter ecological factors and concepts of causation. In Ecological Facrors in Human Detelopmeni (Edited by McGurk H.). North Holland, Amsterdam. 1977. 35. Rutter M.. Yule B., Quinton D.. Rowlands 0.. Yule W. and Berger M. Attainment and adjustment in two geographical areas--III. Some factors accounting for area differences. Br. J. Psychiar. 126, 5X-533, 1975. 36. Surtees P. G.. Dean C.. Ingham J. G., Kreitman N. B.. IMCC ,Miller P. and Sashidharan S. P. Psychiatric disorder in women in an Edinburgh community: association with demographic factors. Br. J. PsFchiut. 142, 238-246. 1983. 37. Bebbington P.. Hurry 1.. Tennant C.. Stun E. and Wing J. K. Epidemiology of mental disorders in Camberwell. Psychol. .bfed. 11, 561-579. 1981. B. P. and Dohrenwend B. S. Sex 38. Dohrenwend differences and psychiatric disorders. Am. J. Social. 81, 1447-1454, 1976. 39. Gove W. R. Sex. marital status and morality. .-Lm. J. Social. 79, 45-67, 1973. 40. Briscoe C. W. and Smith M. D. Depression and marital turmoil. Archs nen. Psvchiar. 29, 812-817. 1973. status and mental disorder: an 41. Bachrach L. L.-Marital analytical review. IVam. Inst. menr. Hlrh 3, 1975. 42. Bloom B. L. Advances and obstacles in prevention of mental disorders. In The .Modern Practice of Community Mental Health (Edited by Schulberg H. C. and Killilea M.). Jossey-Bass. San Francisco. 1982. 43. Paykel E. S. Recent life events and clinical depression. In L@ Stress and Illness (Edited by Gunderson E. K. E. and Rahe R. D.). Charles C. Thomas, Springfield, Ill., 1974. 44. Paykel E. S.. Emms E. M., Fletcher J. and Rassaby E. S. Life events and social support in puerperal depression. Br. J. Psychiar. 136, 339-346, 1980. 45. Murphy E. Social origins of depression in old age. Br. J. Psychiar. 141, 135-142, 1982. E., Cope S. and Teasdale J. Social factors 46 Campbell and affective disorder: an investigation of Brown and Harris’s model. Br. J. Psvchiat. 113, 5-U-553. 1983. 47. Costello C. G. Social factors associated with depression: a retrospective community study. Psychol. Med. 12, 329-339, 1982. C. J. Psychosocial stress and puerperal 48. Martin psychiatric disorder. Presented to the Marce Society, 1982. D. and Davies L. Reliability of 49. Parry G., Shapiro life-event ratings: an independent replication. Br. J. clin. Psychol. 139, 213-220. 1981. to depression and cognitive 50. Campbell E. Vulnerability

Psychiatric

5 I.

52.

53.

54.

55,

56.

57.

58.

59.

60.

cases in community

predisposition: ps,ychosocial correlates of Brown and Harris’s vulnerabihty factors. Paper presented British Psychological Society Annual Conference, 1981. Cope S. Social and psychiatric disturbance in workingclass women with young children in Oxford city. ms. Bebbington P. E., Sturt E.. Tennant C. and Hurry .I. Misfortune and resilience: a community study of women. Psychol. ‘Med. 14, 347-364, 1984. Brown G. W. and Harris T. Disease, distress and depression: a comment. J. Affect. Disord. 4, 1-8, 1982. Paykel E. S., Myers J. K., Dienelt M. N., Klerman G. L.. Lindenthal J. J. and Pepper M. P. Life events and depression: a controlled study. Archs gen. Psychiat. 21, 753-760, 1969. Barrett J. E. (Ed.) The relationship of life events to the onset of neurotic disorders. In Srress and Mental Disorder. pp. 87-110. Raven Press, New York, 1979. Glassner B., Haldipur C. V. and Dessauersmith J. Role loss and working-class manic depression. J. nerr. ment. Dis. 167, 530-54 1. Fava G. A., Munari F., Pavan L. and Kellner R. Life events and depression-a replication. J. Affecf. Disord. 3, 159-165, 1981. Benjaminsen S. Stressful life events preceding the onset of neurotic depression. Psychol. Med. 11, 369-378, 1981. Vadher A. and Ndetei D. Life events and depression in a Kenyan Setting. Br. J. Psychiat. 139, 134-137, 1981. Paykel E. S., Prusoff B. A. and Klerman G. L. The endogenous-neurotic continuum and depression rater

61.

62.

63.

64.

65.

66.

67. 68.

69.

70.

studies

183

independence and factor distributions. J. Psychiat. Res. 8, 73-90. 1971. Leff M. J.. Roatch J. F. and Bunney W. E. Environmental factors preceding the onset of severe depressions, Ps,vchiarry 33, 293-3 I 1, 1970. Thomson K. C. and Hendrie H. C. Environmental stress in primary depressive illness. Archs gen. Psychiar. 26 . 130-132, 19i2. Kedward H. B. and Cooper B. Neurotic disorders in urban practice: a three-year follow-up. J. CON. gen. Pracr. 12, 148-163. 1969. Hagnell 0. and Ojesjo L. A prospective study concerning-mental disorders of a total population investigated in 1947, 1957 and 1972. Acta .psvchiat. stand. Suppl. _ . 263, I-11. 1975. Brown G. W. and Davidson S. Social class, psychiatric disorder of mother. and accidents to children. Lancet 1, 378-381, 1978. Schulberg H. C. and Killilea M. (Eds) The Jlodern Practice of Commrrnirv Mental Health. Jossev-Bass, San Francisco, 1982. . Caplan G. Principles of Prcenlice Psychiatry. Basic Books. New York, 1964. Caplan G. and Killilea M. (Eds) Support Sysrems and Mutual Help: Multidisciplinary Explorations. Grune & Stratton, New York, 1976. Caplan G. Epilogue: personal reflections. In The Modern Practice of Community Mental Health (Edited by Schulberg H. C. and Killilea M.). Jossey-Bass. San Francisco, 1982. Cooper J. E. Crisis Admission Units and Emergency Psychiurric Sexices. Regional Office for Europe. World Health Organization, Copenhagen, 1979.