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Common mental disorders administer this interview is brief in compar- coding was based on the last occupation
ison with other similar instruments. The of the main earner.
Common mental disorders (CMDs) were administration of the CIS±R took an average
assessed using the Revised Clinical Inter- of 30 minutes in this study. This is import-
Employment status
view Schedule (CIS±R) (Lewis et al, al, ant because the length of an interview influ-
1992). This is a structured interview that ences the reliability of the answers, the This was divided in four groups. The
has been fully standardised so that it can refusal rates, and the costs of the fieldwork. `employed', including those people doing
be administered by social survey inter- Lastly, because the validity and reliability unpaid work for a family business. The
viewers. The English and Spanish versions of the CIS±R are comparable to the other `unemployed' category, including those
of the CIS±R have been used extensively commonly used structured interview, Com- who were looking for a job and those
in primary care, occupational and com- posite International Diagnostic Interview individuals who were temporarily un-
munity studies with good reliability and (CIDI) (Lewis et al, al, 1992; Andrews & employed because of sickness or injury.
validity (Lewis et al,
al, 1992). Although the Peters, 1998; Brugha et al,al, 2000). The `economically inactive' group, includ-
CIS±R enquires about 14 common neurotic Most of the questions used to measure ing housewives, students, the retired and
symptoms present during the preceding other variables included in this study were those permanently unable to work because
week, it includes questions to identify the derived from the National Psychiatric of illness or disability.
onset and duration of each episode, so al- Morbidity Survey of Great Britain
lowing categorisation according to ICD± (NPMSGB; Meltzer et al, al, 1995). The Span- Analysis
10 (World Health Organization, 1992) cri- ish questionnaires were translated and
This was approached in two different ways.
teria for the most common disorders. Each back-translated using a standard procedure
Prevalence estimates for the adult popu-
one of the 14 symptoms is rated with an in- recommended by the World Health Organi-
lation of Greater Santiago, Chile, were cal-
dividual score. The total sum of these 14 zation. These questionnaires are available
culated adjusting for differential sampling
scores can be used as a good indicator of upon request from R.A.
and household size by using weights in the
the severity of a CMD. People scoring 12
analysis. The interviewed sample was com-
or above on the CIS±R were regarded as Family type pared by age and gender with population
suffering from a CMD (Lewis et al, al, 1992).
This variable is divided in the same five projections based on the 1992 National
The following ICD±10 diagnoses were
categories as in the NPMSGB. Couples Census results for Greater Santiago, and
included: depressive episodes (F32.00,
were divided into two groups: those with differences were used to further modify
32.01, 32.10, 32.11, 32.2); phobias
or without children. The other three the weights. In view of the multi-stage
(F40.00, 40.01, 40.01, F40.2); panic disor-
groups included were lone parents, `one- random sampling design, 95% confidence
der (F41.1); generalised anxiety disorder
person families', and respondents living intervals (95% CIs) were calculated from
(F41.1); and obsessive±compulsive disorder
with parents. Lone parents and couples standard errors estimated using the survey
(F42). The diagnostic group of mixed anxi-
with children could include children older commands of the computer program
ety and depressive disorder (F42.1) was not
than 16 years provided they were not STATA (STATA, 1999), which takes into
included because the ICD±10 does not pro-
married or they did not have children of account the effect of the sampling strategy
vide an operational definition for research
their own in the same household. The (stratification and clustering) and sampling
purposes. All those subjects who were
`one-person family' does not necessarily weights.
above the threshold on the CIS±R, but
mean a person living alone because this Associations between CMD and socio-
failed to meet explicit ICD±10 criteria for
person may be sharing premises with demographic factors of the respondents
a psychiatric diagnosis were grouped under
another family unit. were examined using odd ratios. These
a category denominated non-specific neuro-
ratios and their 95% CIs were calculated
tic disorder, our equivalent of the mixed
Social class using logistic regression, both before
anxiety and depressive disorder. The preva-
and after adjustment for various socio-
lence rates of specific diagnoses cannot be This variable was based on the household's
demographic factors. The analysis was per-
added up because no attempt was made to main earner's occupation. We used the
formed using STATA survey commands
establish a hierarchy of specific diagnoses. Chilean National Institute of Statistics
adjusting for sampling design effects as well
ICD±10 diagnoses were reached using scale to classify occupations according to:
as differential sampling weights.
computer-assisted algorithms developed by ``prestige, power, economic income, and
Meltzer et al (1995). stability of occupation''. Four categories
The CIS±R was chosen for several rea- were included: (a) low-status and unstable RESULTS
sons. First, because it provides a measure- occupation ± involving manual non-specia-
ment of the severity of symptoms lised working freelance; (b) low-status but Sampling
including those with a sub-threshold inten- stable occupation ± involving manual non- Four thousand six hundred and ninety-
sity. Second, because it allows establishing specialised employees; (c) middle-status oc- three addresses were sampled, 393 of which
ICD±10 diagnoses of the most common dis- cupation ± involving non-manual workers, were declared unusable because they were
orders. Third, because the period of time with no professional qualifications; (d) non-residential or contained only residents
enquired about is reasonably short, dimin- high-status
high-status occupation ± involving non- over the age of 65 years. So effectively
ishing the possibility of memory distortions manual professional or business people with 4300 private households were approached.
about conditions experienced many years prestigious posts. For those households Three thousand eight hundred and seventy
ago. Fourth, because the time taken to where no one was currently employed, subjects were interviewed, a response rate
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1. Weighted sample.
2. Adjusted by age, gender, marital status, education level, social class, employment status, family type, and household Strengths and weaknesses
size.
3. Living together for longer than 1 year without being married. of this study
This study used a structured psychiatric
interview (CIS±R) administered to a repre-
sentative sample of the adult population
Table 3 One-week prevalence of Clinical Interview Schedule ^Revised (CIS
(CIS^R)
^R) `cases' by education, social residing in private households in Santiago,
class and employment status capital of Chile. Experienced lay inter-
viewers underwent an intensive training, in-
cluding several tests of reliability, and were
Sample % Prevalence Crude odds ratio Adjusted odds ratio
closely supervised during the fieldwork.
size (95% CI) 1
(95% CI) (95% CI)1,2
Studies of this design and scale are difficult
Educational level3 to conduct outside Western market eco-
Higher 1314 14.6 (14.5^14.6) 1.00 1.00 nomies. Despite these strengths, this was a
Secondary 1881 24.3 (24.2^24.3) 1.88 (1.47^2.40) 1.34 (1.01^1.78) cross-sectional study involving only one
Primary 669 37.0 (36.8^37.2) 3.44 (2.51^4.71) 2.56 (1.71^3.84) city, thus it would be unwise to generalise
our results to the rest of the country or
Social class4
to reach conclusions about aetiological
Highest 975 12.6 (12.5^12.7) 1.00 1.00
relationships. However, it is still possible
Middle 1403 23.4 (23.3^23.5) 2.12 (1.54^2.91) 1.48 (1.05^2.09)
to identify groups with poor health and
Low 1180 28.6 (28.5^28.7) 2.77 (2.02^3.79) 1.65 (1.11^2.44)
identify strong associations that might
Unstable 297 34.7 (34.3^35.1) 3.67 (2.47^5.46) 1.80 (1.15^2.83) inform future research on causal relation-
Employment status4 ships.
Full-time employed 1822 19.5 (19.4^19.5) 1.00 1.00 The validity of information collected
Economically inactive 1602 29.2 (29.1^29.2) 1.70 (1.35^2.15) 1.30 (0.95^1.78) using clinical interviews administered by
Self-employed 286 31.9 (31.4^32.9) 1.94 (1.20^3.13) 1.46 (0.87^2.44) lay people has been questioned (Brugha et
Unemployed 121 37.7 (36.6^38.8) 2.50 (1.46^4.28) 2.29 (1.27^4.11) al,
al, 1999), but we agree with other research-
ers (Wittchen et al,
al, 1999) in thinking that
1. Weighted sample.
2. Adjusted by age, gender, marital status, education level, social class, employment status, family type, and household on balance this method represents the most
size. cost-efficient way of undertaking com-
3. Primary education is equivalent to less than 8 years, secondary education between 8 and 12 years, and higher
education is more than 12 years. munity surveys of this size. From a practical
4. These variables are described in the Methods section in detail. perspective, it is difficult to conceive of a
2 31
A R AYA E T A L
study over a large geographical area invol- than those found in urban areas of Great CMD and socio-demographic
ving several thousand interviews that could Britain (18%). However, approximately correlates
be administered by psychiatrists in settings the same proportion of ICD±10 diagnosa-
with a shortage of these specialists. We ble conditions and non-specific neurotic Most of the published research from the de-
are not aware of any survey of the house- disorders were present in both samples. It veloping, as well as developed, countries
hold population that has achieved more can be argued that non-specific neurotic has found that women, people who had
than 1000 structured interviews adminis- disorders do not represent `clinically mean- been previously married and people belong-
tered by psychiatrists. ingful' morbidity. However, previous stu- ing to the most socially disadvantaged
In the absence of gold standards one dies have demonstrated the public health groups (education, income, and social class)
can only assess the reliability of measure- importance of sub-threshold and mild psy- have a much higher prevalence of CMD.
ment. Structured interviews administered chiatric disorders (Broadhead et al,
al, 1990). This study replicated these findings, show-
by lay people are as reliable, if not more As far as diagnoses are concerned, higher ing a similar profile of associations between
reliable, than interviews administered by prevalence rates were found for the diag- socio-economic variables and CMD as in
psychiatrists (Lewis et al,
al, 1992; Andrews noses of depressive disorders and phobias Great Britain (Jenkins
( Jenkins et al,
al, 1997) and
& Peters, 1998; Wittchen et al,al, 1999). By in the Chilean compared with the UK Puerto Rico (Canino et al, al, 1987). Women,
using this methodology we can be confident sample: 5.5% v. 2.6% and 4.3% v. 2.1%, divorced or separated individuals, lone par-
that everyone in the study was asked the respectively. ents, those people with less education or be-
same questions and this aids comparison After a literature search covering the longing to lower social class groups and the
within and between studies. period from 1985 up to the present, only unemployed all showed higher prevalence
two Latin American household surveys of rates of common neurotic disorders in both
psychiatric morbidity that had used a countries.
Prevalence of common mental structured interview and a probabilistic The mild but significant association
symptoms sampling design were found in English between young adulthood (age 25±39
Non-specific symptoms such as worries, peer-reviewed journals (Canino et al, al, years) and the presence of a CMD found
irritability, fatigue and sleep problems were 1987; Almeida-Filho et al, al, 1997). Other in the Chilean study persisted after adjust-
by far the most frequent both in the Chilean household surveys have been carried out ing for other variables. This association
and the British urban samples. Specific psy- but do not meet the criteria previously was not found in the British study, which
chological symptoms such as depressed or outlined. showed a trend for the prevalence of mental
anxious mood, essentials for reaching Comparing our results with these two disorders to decrease with greater age ± this
ICD±10 diagnoses, were much less com- surveys is difficult because of methodo- is similar to the trends found in the Chilean
mon in both countries. In the Chilean sur- logical differences. The Puerto Rican study study for other age bands. In keeping with
vey the most common reported symptom (Canino et al,
al, 1987) utilised the Diagnostic our results, some studies have found an
was `worries' (Chile, 38%; GB urban, Interview Schedule (DIS) with an island- increased prevalence of CMD in younger
21%) whereas `fatigue' was the most com- wide probability sample and calculated 6- cohorts, with a decrease with age in other
mon symptom in Great Britain (GB urban, month prevalence estimates of DSM±III groups (Kessler et al, al, 1994). However,
28%; Chile, 30%). The high prevalence of (American Psychiatric Association, 1980) other studies have found a rise in the preva-
these non-specific symptoms might help to diagnoses. The overall prevalence found in lence of CMD with increasing age (Canino
explain the large proportion of people with Puerto Rico is not comparable with our et al,
al, 1987). The higher prevalence of CMD
high scores in the CIS±R who did not meet study because it includes psychotic disor- among young adults in Chile and other
criteria for an ICD±10 diagnosis. ders and substance misuse. However, rates countries deserves further investigation
All symptoms were more frequent in of DSM±III major depression (3%) and because this age group plays a vital role in
the Chilean than in the British sample. In anxiety disorders (7.5%) were similar to any productive economy and these indivi-
both countries all symptoms were more our study. However, it needs to be borne duals could be experiencing more distress
prevalent in women than men. In addition, in mind that our study involved a much as a result of all the pressures of living in
this study contributed to the growing body shorter prevalence period. emerging economies.
of research showing that people from The Brazilian study (Almeida-Filho et On the basis of our study we estimate
many non-Western countries do report al,
al, 1997) was a two-stage design of popu- that about 390 134 people met criteria for
psychological symptoms when asked lation samples from three major cities. A an ICD±10 psychiatric diagnosis in
specifically about them. Notwithstanding subsample of individuals had diagnostic in- Santiago, Chile. If only half of this group
this, somatic complaints and worries about terviews using the Brazilian version of the needed treatment at an average annual cost
physical health were more common in DSM±III Symptom Check-List admin- of US$150, this would total US$74 million
Chile than in urban areas of Great istered by psychiatrists. Comparisons with per annum. Bearing in mind that the entire
Britain: 19% v. 8% and 11% v. 5%, this study are even more cumbersome Chilean health budget was about US$1500
respectively. because their 1-year prevalence estimates million in 1997 and that approximately
were adjusted according to the `potential 10% of this sum went into mental health,
need-for-treatment' judged by the inter- half of the mental health budget would
Prevalence of CMDs viewing psychiatrist. The most common have to be spent on the treatment of these
Prevalence rates of common neurotic dis- diagnoses were anxiety and phobic dis- common neurotic disorders. Based on
orders among adult residents from the orders, with 1-year prevalence estimates this example it is clear that establishing
Greater Santiago area (27%) were higher varying between 7% to 12%. priorities becomes an essential first step in
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Interview. Social Psychiatry and Psychiatric Epidemiology,
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