Australian and New Zealand Journal of Psychiatry (1977) 11: 9
PSYCHIATRIC EPIDEMIOLOGY: ITS USES AND LIMITATIONS* by F. A. WHITLOCK**
Until relatively recent times, what passed as psychiatric epidemiology was largely a matter of hospital admission and discharge statistics. One of the earliest of these exercises is recorded by Hunter and McAlpine (1963) under the heading of The Spital Sermon, preached in 1684 by the Reverend George Hicks, who gave some details of the numbers of “distracted men and women” admitted to the new Bethlem Hospital. Of the 75 admissions, “41 were cured of their lunacy and discharged and 13 distracted persons were buried last year.” Some twenty years earlier, John Graunt in his Bills of Mortality included “The Deaths of Lunaticks”. Like a good many writers since his time Graunt clearly had some difficulty in deciding the causes of the deaths of mentally ill patients, in this instance at Bethlem. For, as he wrote, “all seem to die then of their lunacie who died lunaticks; for there is much difference in computing the number of lunaticks that die (though of fever and all other diseases, unto which lunacie is no Supersedias) and those that die by reason of their madness”. He also took note of “men that made away with themselves who are yet another sort of madmen, attempting to ease themselves of pain by leaping into hell; or else are yet more mad, so as to think there is no such place”. One hundred years later we find William Battie providing tables of discharge from St. Luke’s Hospital for Lunatics. Whatever else these statistics show they appear to demonstrate that it was, judging by the mortality rates, safer to be an ordinary patient than one “in the House at 5 shillings a week”.
*Squibb Academic Address - Presented at the 13th Annual Congress of the Australian and New Zealand College of Psychiatrists; Adelaide, October 1976. **Professor of Psychiatry, University of Queensland.
A more comprehensive attempt at providing statistical information on patients admitted to the Bethlem Hospital was made by William Black in 1810. He recorded the ages of those admitted over a period of 15 years, a total of 2850, of whom 743 were designated as “mischievous” and 886 as “not mischievous”. As far as I can tell, being mischievous generally involved violence in the shape of suicide or murder, As Black records, “There are above a score of atrocious murderers; there are parricides and butchers of their offspring.” Undoubtedly Black had no hesitation in expressing vigorously his opinions about homicidal, mentally deranged persons who, having escaped the rigours of the law, were now housed in the hospital. In 1845 John Thurnam published his observations and essays on the statistics of insanity in which he attempted to carry out large-scale surveys based on the use of a questionnaire directed to members o fthe Association of Medical Officers of Hospitals for the Insane; an advance on the headcounting procedures of former writers. The questionnaire was designed to elicit information about the patients’ past and present circumstances, anything that might be of aetiological importance and details of the illness itself. In the meantime William Farr (1841) at the Registrar General’s Office was patiently putting together his statistics of English lunatic asylums and a report upon the mortality of lunatics. Similar exercises were under way in France in the hands of Esquirol, and in the U.S.A. Amariah Brigham (1832) made estimates of the number of insane pZTsonsIn’ the Union based on figures obtained from the state of Connecticut where, on inquiry, it was reported that, “There were 1000 individuals within the bounds of the state mentarderanged”, and that the conditions of many of them were “totally deplorable”. On a population basis this was a rate of oAe for every 262 inhabitants, a figure which Brigham regarded as remarkably high. From these and other observations, which included the belief that there was
Downloaded from anp.sagepub.com at Harvard Libraries on July 12, 2015
10
PSYCHIATRIC EPIDEMIOLOGY
li&e in the way of lunacy in China, Turkey and. Spain, Brigham decided that, “the causes of the great Fievalence of this disease in this country” included too constant and too powerful excitement of the mindin the pursuit of wealth, office, political distinction etc., too early cultivation of the mind in childhood, neglect of physical education and, last but not least, “the general and powerful excitement of the female m m ’ . In contrast to Brigham Dr. John Gray (1871), basing his observations on admissions to the State Mental Hospital at Utica over a period of 28 years, concluded that p h s 1 predominated overwhelmingly over moral causes of insanity..
Another understandable interest was the effects of treatment which again ran into difficulties, largely because the precise delineation of psychiatric syndromes did not exist and because the causeswhether moral or physical -generally rested on untested observations and speculations. As Bacon once commented, “Men observe when Things Hit, and not when they Miss: and commit to Memory the one And forget and pass over the other”. A pleasant exception to this criticism was the controlled clinical trial performed by John Haygarth in 1800 when he pair of brass used a device known as a tractor-a and iron rods thought to give off an electric current By the end of the 19th century the general trend of -and a dummy replica made of wood. It had been psychiatric epidemiology and statistical inquiries was claimed that tractors were particularly efficacious in fairly clear. The majority of studies which I have relieving pain but that they also cured anything from cited were concerned with a number of problems gout to epilepsy. Haygarth found that both the which, in theory at least, could be solved by epi- “active” instrument and placebo were equally effecdemiological methods. Yet, not surprisingly, the tive. Mortality rates among the mentally ill appear to results fell far short of expectations. have preoccupied hospital statisticians from the One of the perennial fears. that appears to have earliest times, and it is probably correct to say that haunted administrators and physicians was the belief the subject is one which would still repay the closest that mental illness was increasing to such a degree and most detailed investigation. The biology of ageing that some writers referred to “the current epidemic. is a matter of great interest and the relationship of of insanity”. All the data alleged to support this psychosis to physical disease of all kinds is one which depressing conclusion were based essentially on hos- requires the combined efforts of the clinician, the pital admission statistics. Today we are fully f a m E r pathologist, the biochemist and the immunologist to of extrapolating from hospital statis- determine. with the -f tics to the general population, and clearly another kind of investigation was required before concluding Compared to the epidemiological work in other that inception rates of mental illness were increasing. branches of medicine it has to be said that similar attempts in psychiatry in the 19th century were insigRelated to this kind of inquiry were problems of nificant. There were no Chadwicks or John Snows aetiology which again were not solved by speculations in the mental hospitals and no psychiatric equivalent based on hospital admissions. In the 18th centuy to the handle of the Broad Street Pump to bring Che ne expressed alarm at the rising tide of mental postulated epidemics of mental disease under control. i-+i ness which was ascribed to a number of aetiological In the great majority of psychiatric disorders we factors including the English climate and, favourite can rarely delineate a single cause and, consequently, among contemporary writers, “the rush and tear of we have to deal with concepts of multiple aetiology modern life”. Stage coache? were travelling faster which will be all the harder to sort out compareda n a t h e r a i l w a y age was just ahead. To the more with the single removable or preventable c a u s e n conservative members of society advances in the infectious disease like cholera. If these strictures means of transportation have always presented them- appear a little unfair to 19th century investigators selves as threats to mental stability and personal it has to be said that we do not necessarily appear safety, a view not entirely unwarranted with respect to be doing much better ourselves. The reasons for to modern road transport. Nonetheless, in the 19th the difficulties inherent in psychiatric epidemiological century opinions on aetiology were dogmatic and research are well known: our inability to set precise unsoundly based in manv instances. G.P.I., for criteria for the diagnosis of specific mental disorders; example,-was attributed b; George B u r r o w 1 8 2 8 our limited understanding of the aetlology of mO& to excessive exposure to wet and damp and the viLf- of the conditions we treat; the multivaried n wf. situdes ot temperature, while excessive libertinisq the interaction between the organism and the enviroF(nearer the mark) and abuse of mercury and spiritous m a a n d the consequent difficulfy in idzntifying clear liquors were considerea to be possible causes. As relationships between symptoms and sumosed c w e; u s 3 he indicated the wear and tear of modern the enormous complexity of the central nervous society coupled with “moral agony”, a term which s c m which should be taken as our starting point included remorse from profligacy, loss of c h w in trying to understand the phenomena of ormal and bankruptcy, madness ot relatives, disgrace. abnormal psychological functions; our recent ten ency malnutrition.. This kind of grapeshot approach to to sideste this difficulty by relying on social rather aetiology at least made fairly certain that one possible t an me ical conceptse of - id cause would be hit but no advances were made until empirical nature of our treatme which at times the precise organism responsible for the disease was have all the imprecision of a blast from a blunderbuss tracked down and eliminated from the patient’s central rather than the niceness of a finely aimed rifle. In 1962 Hill observed, “The historical development of nervous system by modern chemotherapy.
A
Downloaded from anp.sagepub.com at Harvard Libraries on July 12, 2015
+
F. A. WHITLOCK psychiatry as a scientific subject is characterised by a series of expectations of high promise doomed t9 disappointment”. He went on to foreshadow a bright future for psychiatric epidemiology. Fourteen years later one might justifiably ask whether this also has been another approach to the tough conundrums of psychiatric aetiology and prevention which, like others, has proved less rewarding than anticipated. Perhaps at this stage we ought to start afresh and try to define our objectives and methods to see, if possible, where we have gone wrong. Numerous definitions of epidemiology exist from the most general such as Susser’s (1973) ‘The study of tbe distribution and deterof s w of P human populatiojs’ to the narrower concept of C s r ( 1973) who categorised psychiatric epidemi. . . . ology as “that branch of the s o e c r a l l t v m I s (;plj-~ cerned with the incidence, p r e v a l m d istributim of mental disorder in the populatiofi”. 1 must confess that 1 find the pursuit of investigations of this kind a singularly sterile activity, largely because it is difficult to see what possible purpose such enterprises have other than providing academics with respectable justifications for claims on research funds. Headcounting to establish prevalence norms is tedious and rarely can be carried out in any comprehensive fashion by those trained to recognise and treat mental disorders - however these might be defined. At the end of the operation we have a set of data which allegedly are valuable for planners and administrators who have to design psvchiatric services to cope with the numbers of mentally disordered persons in the community as a whole. This may be a laudable ideal, but in real life the development of medical services is more determined by pop r - e s and the money available than by any theoretical concepts of need based on population surveys. No doubt we should aim to make better use of such surveys but, faced with the-difficulty of identifying with any precision at all the extent
PSYCHIATRIC EPIDEMIOLOGY: ITS USES AND LIMITATIONS* by F. A. WHITLOCK**
Until relatively recent times, what passed as psychiatric epidemiology was largely a matter of hospital admission and discharge statistics. One of the earliest of these exercises is recorded by Hunter and McAlpine (1963) under the heading of The Spital Sermon, preached in 1684 by the Reverend George Hicks, who gave some details of the numbers of “distracted men and women” admitted to the new Bethlem Hospital. Of the 75 admissions, “41 were cured of their lunacy and discharged and 13 distracted persons were buried last year.” Some twenty years earlier, John Graunt in his Bills of Mortality included “The Deaths of Lunaticks”. Like a good many writers since his time Graunt clearly had some difficulty in deciding the causes of the deaths of mentally ill patients, in this instance at Bethlem. For, as he wrote, “all seem to die then of their lunacie who died lunaticks; for there is much difference in computing the number of lunaticks that die (though of fever and all other diseases, unto which lunacie is no Supersedias) and those that die by reason of their madness”. He also took note of “men that made away with themselves who are yet another sort of madmen, attempting to ease themselves of pain by leaping into hell; or else are yet more mad, so as to think there is no such place”. One hundred years later we find William Battie providing tables of discharge from St. Luke’s Hospital for Lunatics. Whatever else these statistics show they appear to demonstrate that it was, judging by the mortality rates, safer to be an ordinary patient than one “in the House at 5 shillings a week”.
*Squibb Academic Address - Presented at the 13th Annual Congress of the Australian and New Zealand College of Psychiatrists; Adelaide, October 1976. **Professor of Psychiatry, University of Queensland.
A more comprehensive attempt at providing statistical information on patients admitted to the Bethlem Hospital was made by William Black in 1810. He recorded the ages of those admitted over a period of 15 years, a total of 2850, of whom 743 were designated as “mischievous” and 886 as “not mischievous”. As far as I can tell, being mischievous generally involved violence in the shape of suicide or murder, As Black records, “There are above a score of atrocious murderers; there are parricides and butchers of their offspring.” Undoubtedly Black had no hesitation in expressing vigorously his opinions about homicidal, mentally deranged persons who, having escaped the rigours of the law, were now housed in the hospital. In 1845 John Thurnam published his observations and essays on the statistics of insanity in which he attempted to carry out large-scale surveys based on the use of a questionnaire directed to members o fthe Association of Medical Officers of Hospitals for the Insane; an advance on the headcounting procedures of former writers. The questionnaire was designed to elicit information about the patients’ past and present circumstances, anything that might be of aetiological importance and details of the illness itself. In the meantime William Farr (1841) at the Registrar General’s Office was patiently putting together his statistics of English lunatic asylums and a report upon the mortality of lunatics. Similar exercises were under way in France in the hands of Esquirol, and in the U.S.A. Amariah Brigham (1832) made estimates of the number of insane pZTsonsIn’ the Union based on figures obtained from the state of Connecticut where, on inquiry, it was reported that, “There were 1000 individuals within the bounds of the state mentarderanged”, and that the conditions of many of them were “totally deplorable”. On a population basis this was a rate of oAe for every 262 inhabitants, a figure which Brigham regarded as remarkably high. From these and other observations, which included the belief that there was
Downloaded from anp.sagepub.com at Harvard Libraries on July 12, 2015
10
PSYCHIATRIC EPIDEMIOLOGY
li&e in the way of lunacy in China, Turkey and. Spain, Brigham decided that, “the causes of the great Fievalence of this disease in this country” included too constant and too powerful excitement of the mindin the pursuit of wealth, office, political distinction etc., too early cultivation of the mind in childhood, neglect of physical education and, last but not least, “the general and powerful excitement of the female m m ’ . In contrast to Brigham Dr. John Gray (1871), basing his observations on admissions to the State Mental Hospital at Utica over a period of 28 years, concluded that p h s 1 predominated overwhelmingly over moral causes of insanity..
Another understandable interest was the effects of treatment which again ran into difficulties, largely because the precise delineation of psychiatric syndromes did not exist and because the causeswhether moral or physical -generally rested on untested observations and speculations. As Bacon once commented, “Men observe when Things Hit, and not when they Miss: and commit to Memory the one And forget and pass over the other”. A pleasant exception to this criticism was the controlled clinical trial performed by John Haygarth in 1800 when he pair of brass used a device known as a tractor-a and iron rods thought to give off an electric current By the end of the 19th century the general trend of -and a dummy replica made of wood. It had been psychiatric epidemiology and statistical inquiries was claimed that tractors were particularly efficacious in fairly clear. The majority of studies which I have relieving pain but that they also cured anything from cited were concerned with a number of problems gout to epilepsy. Haygarth found that both the which, in theory at least, could be solved by epi- “active” instrument and placebo were equally effecdemiological methods. Yet, not surprisingly, the tive. Mortality rates among the mentally ill appear to results fell far short of expectations. have preoccupied hospital statisticians from the One of the perennial fears. that appears to have earliest times, and it is probably correct to say that haunted administrators and physicians was the belief the subject is one which would still repay the closest that mental illness was increasing to such a degree and most detailed investigation. The biology of ageing that some writers referred to “the current epidemic. is a matter of great interest and the relationship of of insanity”. All the data alleged to support this psychosis to physical disease of all kinds is one which depressing conclusion were based essentially on hos- requires the combined efforts of the clinician, the pital admission statistics. Today we are fully f a m E r pathologist, the biochemist and the immunologist to of extrapolating from hospital statis- determine. with the -f tics to the general population, and clearly another kind of investigation was required before concluding Compared to the epidemiological work in other that inception rates of mental illness were increasing. branches of medicine it has to be said that similar attempts in psychiatry in the 19th century were insigRelated to this kind of inquiry were problems of nificant. There were no Chadwicks or John Snows aetiology which again were not solved by speculations in the mental hospitals and no psychiatric equivalent based on hospital admissions. In the 18th centuy to the handle of the Broad Street Pump to bring Che ne expressed alarm at the rising tide of mental postulated epidemics of mental disease under control. i-+i ness which was ascribed to a number of aetiological In the great majority of psychiatric disorders we factors including the English climate and, favourite can rarely delineate a single cause and, consequently, among contemporary writers, “the rush and tear of we have to deal with concepts of multiple aetiology modern life”. Stage coache? were travelling faster which will be all the harder to sort out compareda n a t h e r a i l w a y age was just ahead. To the more with the single removable or preventable c a u s e n conservative members of society advances in the infectious disease like cholera. If these strictures means of transportation have always presented them- appear a little unfair to 19th century investigators selves as threats to mental stability and personal it has to be said that we do not necessarily appear safety, a view not entirely unwarranted with respect to be doing much better ourselves. The reasons for to modern road transport. Nonetheless, in the 19th the difficulties inherent in psychiatric epidemiological century opinions on aetiology were dogmatic and research are well known: our inability to set precise unsoundly based in manv instances. G.P.I., for criteria for the diagnosis of specific mental disorders; example,-was attributed b; George B u r r o w 1 8 2 8 our limited understanding of the aetlology of mO& to excessive exposure to wet and damp and the viLf- of the conditions we treat; the multivaried n wf. situdes ot temperature, while excessive libertinisq the interaction between the organism and the enviroF(nearer the mark) and abuse of mercury and spiritous m a a n d the consequent difficulfy in idzntifying clear liquors were considerea to be possible causes. As relationships between symptoms and sumosed c w e; u s 3 he indicated the wear and tear of modern the enormous complexity of the central nervous society coupled with “moral agony”, a term which s c m which should be taken as our starting point included remorse from profligacy, loss of c h w in trying to understand the phenomena of ormal and bankruptcy, madness ot relatives, disgrace. abnormal psychological functions; our recent ten ency malnutrition.. This kind of grapeshot approach to to sideste this difficulty by relying on social rather aetiology at least made fairly certain that one possible t an me ical conceptse of - id cause would be hit but no advances were made until empirical nature of our treatme which at times the precise organism responsible for the disease was have all the imprecision of a blast from a blunderbuss tracked down and eliminated from the patient’s central rather than the niceness of a finely aimed rifle. In 1962 Hill observed, “The historical development of nervous system by modern chemotherapy.
A
Downloaded from anp.sagepub.com at Harvard Libraries on July 12, 2015
+
F. A. WHITLOCK psychiatry as a scientific subject is characterised by a series of expectations of high promise doomed t9 disappointment”. He went on to foreshadow a bright future for psychiatric epidemiology. Fourteen years later one might justifiably ask whether this also has been another approach to the tough conundrums of psychiatric aetiology and prevention which, like others, has proved less rewarding than anticipated. Perhaps at this stage we ought to start afresh and try to define our objectives and methods to see, if possible, where we have gone wrong. Numerous definitions of epidemiology exist from the most general such as Susser’s (1973) ‘The study of tbe distribution and deterof s w of P human populatiojs’ to the narrower concept of C s r ( 1973) who categorised psychiatric epidemi. . . . ology as “that branch of the s o e c r a l l t v m I s (;plj-~ cerned with the incidence, p r e v a l m d istributim of mental disorder in the populatiofi”. 1 must confess that 1 find the pursuit of investigations of this kind a singularly sterile activity, largely because it is difficult to see what possible purpose such enterprises have other than providing academics with respectable justifications for claims on research funds. Headcounting to establish prevalence norms is tedious and rarely can be carried out in any comprehensive fashion by those trained to recognise and treat mental disorders - however these might be defined. At the end of the operation we have a set of data which allegedly are valuable for planners and administrators who have to design psvchiatric services to cope with the numbers of mentally disordered persons in the community as a whole. This may be a laudable ideal, but in real life the development of medical services is more determined by pop r - e s and the money available than by any theoretical concepts of need based on population surveys. No doubt we should aim to make better use of such surveys but, faced with the-difficulty of identifying with any precision at all the extent
