JACK D. MASER AND NORMAN DINGES

COMORBIDITY: MEANING AND USES IN CROSS-CULTURAL CLINICAL RESEARCH 1 ABSTRACT. American Indians and Alaska Natives were the subject of a workshop sponsored by the National Institute of Mental Health and the Indian Health Service. Comorbidity of anxiety, depression, and substance abuse is highly prevalent in these two populations, and this was the focus of the meeting. This paper introduces the topic of psychiatric comorbidity, and considers the topics of culture, psychiatric diagnosis, and assessment. Future research directions and a brief summary of the papers presented at the workshop, which are included in this issue, are provided.

INTRODUCTION On April 8-10, 1991, the National Institute of Mental Health (NIMH) and the Indian Health Service jointly sponsored a workshop 2 on the assessment of diagnosis of three highly comorbid disorders in American Indians and Alaska Natives: Depression, Anxiety and Substance Abuse. The goals of the workshop were: 1) to enhance awareness of comorbidity issues, especially regarding the research in which these clinical investigators were actively engaged; and 2) to learn if there are special issues of psychopathology and comorbidity that affect American Indian and Alaska Native populations. Both goals could be incorporated into Fabrega's (1990) definition of ethnomedicine: the study of how medical problems are realized and dealt with in different societies. The focus at the workshop, and in this issue of Culture, Medicine and Psychiatry, is on three psychiatric disorders that are known by clinicians to frequently co-occur: depression, anxiety and substance abuse (Maser and Cloninger 1990). The papers in this issue will consider the prevalence of these disorders, separately and together, as well as the meaning of the term "comorbidity." Moreover, many of the papers that follow will discuss, in whole or part, the topic of assessment. This format is only proper since assessment may be seen as being in the service of psychiatric diagnosis. At the heart of modern diagnosis is the official nomenclature, the Diagnostic and Statistical Manual, 3rd Edition and 3rd Edition Revised (DSM-III, American Psychiatric Association, 1980; DSM-III-R, 1987). In many respects the DSM can claim success throughout much of the world (Maser, Kaelber & Weise 1991), but readers of this journal have long known that scant attention is paid to cross-cultural diagnostic issues by either the DSM or the International Classification of Diseases (ICD-IO, World Health Organization, 1977). In this respect the two major nomenclatures in the world are imperfect in their service Culture, Medicine and Psychiatry 16: 409-425, 1993. © 1993 KluwerAcademic Publishers. Printed in the Netherlands.

410

JACK D. MASER AND NORMAN DINGES

to diagnostic reality. This imperfection will be seen to include comorbidity as well as cross-cultural psychopathology. A simple reading of the DSM would lead one to believe that homogenous subtypes constitute the bulk of patients to be found in clinical settings, but it is the rare patient that has a single disorder. In clinical research, the subjects section of a publication may say that patients with panic attacks constituted the sample. However even though the fact goes unreported, clinical researchers know that many of these patients suffered from depression, phobias, and substance abuse. We know it from our own clinical experience and from data. For example, data from the NIMH Epidemiological Catchment Area Study (ECA, Boyd et al. 1984), shows large odds ratios for panic, agoraphobia, simple phobia, and obsessive compulsive disorder to be comorbid with major depressive disorder. Thus, if you have major depressive disorder, the odds of having a simple phobia are nine times greater than someone who does not have major depressive disorder. The 1984 ECA study replicated Sturt et al. (1982) in clearly showing that if you have one mental disorder, you are very likely to have more than one. There is little representation of American Indian or Alaska Natives among NIMH Epidemiological Catchment Area Study populations, and it is unknown whether similar odds ratios would prevail.

CULTURE AND DIAGNOSIS Culture or ethnicity complicates diagnosis. One way by which this complication occurs is through an increase or decrease in the likelihood of observing a given symptom or modifying symptom expression in ways not commonly observed in the larger population. Good and Kleinman (1985) believe that cross-cultural research makes clear that the phenomenology of disorders, the "meaningful forms through which distress is articulated and constituted as social reality, varies in quite significant ways across cultures" (p. 298). Age of onset, symptomatology, natural course of the disorder, its social distribution, reaction to treatment, and consequences to the patient are factors that may vary with culture. Similarly, cultural variations are commonly observed in the explanatory beliefs of patients which influence symptom presentations, attributed etiology, perceived therapeutic sources, and definitions of cure. Both the American nomenclature, DSM-III-R, and the official world nomenclature, ICD-9, do not include so-called culture specific disorders. Here we are thinking of such fright disorders as latah in Malaysia and Indonesia, koro in India and China, and susto in Latin America, as well as other culture-specific disorders of American Indians and Alaska Natives such as piblotok (Arctic hysteria) and Kayak-angst, to name some of the more dramatic forms. Given the massive migration into the United States of Hispanics and Asians, as well as the

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

411

rapid social changes among Indian and Native cultures, culture specific disorders should be expected to appear with increased frequency and need to be identified in the DSM. The impact that the DSM-III (and DSM-III-R) has had around the world, would also seem to demand that this nomenclature (and certainly the ICD) be informed by a cross-cultural perspective (Maser, Kaelber & Weise 1991). Unfortunately, we are far from such a state of affairs. Lock (1987) has argued that the decontextualized, acultural approach to focusing on only signs and symptoms that are tangible and reliable is itself culture-bound by its origins in Aristotelian logic which seeks to divide and establish the boundaries of symptoms and their groupings. For example, Lock describes reducing the Japanese psychiatric syndrome of taijin kyofusho to but another example of social phobia by DSM-III-R criteria. Such an attempt illustrates how the goal of a decontextualized diagnosis is at best culturally parochial and at worst sterile and lacking in explanatory or therapeutic value. Continuing with the example of taijin kyofusho, Kirmayer (1991) further elaborates its heuristic potential for comparative diagnostic purposes by a convincing analysis of it as a pathological amplification of Japanese culturespecific concerns about social presentation of self and interpersonal behaviors which may impact negatively on the well being of others. Both Lock and Kirmayer highlight the explanatory limitations and therapeutic usefulness of single classification systems. They show that the "inclusion of cultural variation in psychiatric diagnoses must begin by making explicit the intended use of the classification because different social contexts and clinical goals demand alternative diagnostic schemes" (Kirmayer 1991: p. 19). An example of a psychopathology symptom that shows some specificity for race, was recently discussed by Neal and Turner (1991). They discuss a condition that occurs when an individual is awakening from or falling asleep. During this period, the individual is unable to move their body and may experience vivid hallucinations or feelings of acute danger. When paralysis ends, the individual sits up and experiences panic-like symptoms, including tachycardia, hyperventilation and fear (Bell et al. 1984). Caucasians might experience isolated sleep paralysis once in a life time (Everett 1963; G.B. Goode 1962; and possibly Ness 1978), but it is both more common and tends to recur among African Americans (Bell, Dixie-Bell & Thompson 1986). Perhaps there are symptoms in American Indians or Alaska Natives that also are specific to these populations and should be described in a psychiatric nomenclature. American Indians and Alaska Natives have considerable potential for informing the DSM about culture specific, or at least culturally influenced, disorders. Just to use the terms "American Indians" and "Alaska Natives" ignores their cultural diversity. As we study disorders across tribes, we are likely to confront differences in symptom expression. Rather than being able to conveniently say that a symptom or syndrome is unique to the Indian popula-

412

JACK D. MASER AND NORMAN DINGES

tion, we must deal with a further examination of subtypes based on cultural differences between tribes. Such an exercise tells us something about psychopathology that was missed when the DSM and ICD were designed. Psychopathology found in American Indians and Alaska Natives may also be helpful in the design of clinical research. Nested as they are in the larger population (socially and statistically), some have assimilated and experienced serious intercultural stressors, while others have chosen to remain in their distinctive cultures and to cope with intracultural stressors. Therefore, if one wished to compare assimilated with non-assimilated samples on symptomatology, quality of life, course of illness, and treatment service utilization, this comparison would be possible. Such an approach could lead to creative uses of service utilization data and understanding of the cultural context to explore explanations for the development of intraculturally influenced psychopathologics, as illustrated in research by Levy, Kunitz and Henderson (1987). Attitudes toward maintenance of one's cultural identity and the value placed on maintaining intergroup relations, as well as the degree of psychosocial change entailed in the process of acculturation are also important factors to be considered (Berry & Kim 1988).

Comorbidity What is comorbidity? The answer depends upon who is providing the answer. Alvin Feinstein coined the term in 1970. He would say that comorbidity is "Any distinct additional clinical entity that has existed or that may occur during the clinical course of a patient who has the index disease under study." For example, endogenous depression, which has a particular set of variables controlling its onset and course may be comorbid with substance abuse, a condition whose controlling variables may include depression, but are certainly linked to addiction. Psychiatric epidemiologists would put a different twist on comorbidity. They would speak of "relative risk" and use the odds ratio, a likelihood statistic, as expressing the probability of one disorder being associated with another. For example, Regier et al. (1990), using the community sample data of the ECA study, found a relative risk or odds ratio of 7.9 for bipolar I disorder (with mania) and substance abuse. That is, if you are bipolar, compared with someone who is not bipolar, you are 7.9 times more likely to be abusing a chemical substance. We should add that morbidity refers to a disease process, and we are taking the liberty of equating disease with disorder; but we do not take the same liberty in extending the use of "comorbid" to signs and symptoms. Symptoms may co-occur or co-exist, but they are not disease processes, and therefore, cannot by definition, be comorbid.

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

413

What implications do comorbid disorders have for the field of psychopathology? The most important implication is that we are studying clinical phenomena as they really exist. Another is that comorbidity affects how we view the existing categories of the DSM-III-R, and therefore, how we go about making diagnoses. For example, Weissman's study of anxiety and depression without DSM-III diagnostic hierarchies led the way to abolition of most hierarchies in DSM-III-R. Another implication of comorbidity is for treatment. Consider the example of mental disorders and substance abuse disorders. We have long suspected that mental disorders and substance abuse/dependence disorders co-occur at a high incidence. A further assumption is that treating mental disorders properly would lead to a major reduction in substance abuse. Nevertheless, we lack an empirically gathered knowledge base on the degree to which such a premise is true. And this lack of knowledge may have critical consequences for populations in which mental disorders and substance abuse disorders are thought to be highly comorbid, as they are among American Indians and Alaska Natives. In regard to the implications of comorbidity for research strategy, we believe that scientists should always challenge their basic assumptions. The most basic of all our many assumptions is that the DSM-III-R accurately mirrors the mentally ill patient. Assessment of co-occurring symptoms and comorbid disorders can challenge that assumption by revealing patients who do not meet the existing categories. Current assessment approaches encounter numerous difficulties in establishing the presence of single disorder syndromes among culturally different patients when using diagnostic schema derived from Western oriented criteria of dysfunction. Diagnosis of comorbid conditions may prove far more difficult, especially when such conditions remain obscure, without knowledge of the culturally salient questions that are most important in eliciting the symptom reports necessary to determine the co-existence of relatively distinct disorders. If past research has not taken comorbidity into account, how much confidence can be placed in the research database of psychiatry and clinical psychology? Science demands replicability of findings, and if a study reports a finding with depressives, yet fails to assess and report co-existing panic attacks and personality disorders, the probability seems remote that the study can be replicated with another sample of depressives. We know that much of the published literature has failed to report comorbid diagnoses. Thus, comorbidity has implications for the confidence that we can place in replicating these studies. Such considerations should be prominent in the implementation of forthcoming psychiatric epidemiology studies with culturally different populations in the United States, and in the rest of the world. There is also increasing evidence that patients with more than one disorder are more likely than patients with a single disorder to use hospital beds, to visit the

414

JACK D. MASER AND NORMAN DINGES

emergency room more often, to respond more slowly to treatment, to commit suicide and generally die earlier, and to have a generally poorer prognosis. The research on obstacles to mental health service utilization may be productively re-framed to take into account the greater potential comorbidity among culturally different patients. The seminal studies were done in an era when comorbidity was not recognized or diagnosed and therefore probably underemphasized as a potent obstacle to seeking or remaining in treatment. In many cases we cannot be certain whether two disorders temporally separated evolve out of the natural course of one of the illnesses or are examples of diagnostic instability, or have no relationship to one another. Below we cite several studies which led us to raise these questions. Keane and Wolfe (1990) compared their clinical sample of post-traumatic stress disorder (PTSD) patients with a community sample for prevalence of comorbidity. Comorbidity was higher in this clinic for PTSD and substance abuse, PTSD and depression, and PTSD and dysthymia than in the community sample. The well-replicated fact - higher comorbidity in the clinic than in the community - emphasizes an important prevalence finding. Across nearly every study showing evidence of comorbidity, one consistent finding is that comorbidity is greater in treatment settings than in the community. Berkson was the first to report this in 1946, and today the phenomenon is called Berkson's bias. True comorbidity rates are "biased upward in treatment settings because persons with comorbid disorders seek treatment more readily than persons with a single disorder. Studies of Berkson's Bias have not been replicated to any extent with culturally different populations. There is, however, little reason to believe that there would be any less, and some reasons to expect that there may be considerably mor6, comorbidity due to the greater severity of disorder that appears necessary to initiate a clinical referral among such populations. Regier et al. (1990) recently published an important ECA paper on comorbidity in the Journal of the American Medical Association. One finding was that a third of all adults have a lifetime prevalence of any alcohol or drug abuse or mental disorder. For the disorders that are central to this paper, affective disorders had a lifetime prevalence of 8.3%, anxiety disorders 14.6%, and any substance use disorder, 16.7% of the population. Now consider that among the affective disorders 13.4% have a comorbid alcohol disorder and 26.4% have a comorbidity with other drugs of abuse. In regard to the 14.6% of the population with an anxiety disorder, 19.4% and 28.3% of these persons have an alcohol and substance abuse disorder, respectively. Comorbidity can occur with two or more disorders simultaneously or with these disorders temporally separated. Tyrer and his colleagues studied temporally separated comorbidity in the following way. Their interest was in diagnostic instability or symptom drift. Seventy-eight patients were followed for two years and during this period

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

415

they were assessed four times. At the time of the first assessment, 51 of the 78 were given an ICD diagnosis of depressive neurosis, 16 of phobic neurosis, and 11 of anxiety neurosis. Anxiety neurosis roughly corresponds to panic disorder with agoraphobia. These patients were treated, so some reduction in symptom expression might be expected. The improvement that occurred, however, was most marked in the first four months; the next 20 months saw only slight changes. Over this 24 month period anxiety symptoms were consistently high in number and hypochondriacal symptoms consistently low. Despite this consistency, there was considerable variation among symptoms over the course of an individual's illness. In only three of the 78 patients did the same symptom group predominate on all four occasions of testing. Tyrer's results suggest that an unyielding distinction between anxiety and depressive disorders will have little predictive validity. Moreover, phobic disorders might best be viewed as a mixture of phobia, anxiety and depression. Such a cluster of symptoms is not represented in DSM-III-R as a single category. This study points out that, at least for anxiety and depression, symptoms and syndromes are relatively unstable over time, and they tend to co-occur in ways not predicted by either the ICD or DSM. Tyrer's observation is that over time, individuals pass, chameleon-like, through different diagnostic hues, depending on the nature of the stress that they encounter. Cultural differences between diagnostician and patient increase the probability that such complex variations in symptom pictures over time will go undetected and inappropriately diagnosed. Similarly, cultural variations in perceived stressors over time may alter symptom and syndrome presentations in ways which lead to false conclusions about therapeutic improvement or lack thereof among culturally different patients. For Tyrer, concern about the validity and stability of a diagnostic entity centered on the reliability of the diagnostic criteria. This concern should be even greater when dealing with cross-cultural samples. If one or more of the diagnostic criteria are not reliable in American Indian/Alaska Native populations, then the DSM-IV ought to reflect that fact. Similarly, if there is one or more diagnostic criteria that cross-cultural researchers have found useful, but is not reflected in the DSM, like isolated sleep paralysis preceding panic-like symptoms, that too should come to the attention of the designers of the nomenclature. We turn to another concern related to how these symptoms cluster together, using depression as an example. If you count the diagnostic criteria for depression you will find between 9 and 15, depending on your method of counting. Nine if you say that significant weight loss or weight gain together count as one criterion; 15 if you count each member of the pair separately. Other examples are insomnia or hypersomnia, psychomotor agitation or retardation, and feelings of worthlessness or excessive guilt. Of these 9 or 15 criteria, a patient need exhibit only 5 to be classified as depressed.

416

JACK D. MASER AND NORMAN DINGES

The fact that there is a range of possible criteria applied to the prototype allows nosologists to call the system polythetic. It also means that two patients diagnosed as having a major depressive episode may have no overlapping symptoms. One patient may present with depressed mood, weight loss, insomnia, fatigue, and psychomotor retardation. A second can present with loss of pleasure in everyday activities, recurrent thoughts of death, indecisiveness, excessive guilt, and psychomotor agitation. We can even insert a third patient, some of whose symptoms are different from the first two. Inclusion of patients in a clinical research sample according to a polythetic classification system probably poses a problem for replicating those studies. Now consider comorbidity with anxiety, so we have patients with mixed anxiety/depression. Given the polythetic diagnostic criteria of, say, panic disorder, generalized anxiety disorder and post-traumatic stress disorder, the heterogeneity of such a sample becomes appalling for someone attempting to replicate.

Assessment

The first issue in any consideration of assessment is that most of what we have said thus far may not really be any different for the populations being considered in this journal issue than for the population at large. In other words, the diagnostic criteria, associated features, predisposing factors, familial pattern, and course of illness may be pretty much the same within the boundaries of the United States and Canada. It may be that ethnicity means little to the core features of a mental disorder or to its expression. It may also be that core features are relatively invariant across cultures but that expression varies widely. Not only is an accurate description of diagnostic criteria necessary, but assessment of those core and associated features is equally important. We may need only to ask the culturally correct question in order to reveal the existence of depressed mood or sudden, unexpected onset of extreme fear. But asking the culturally correct question(s) can be harder than it may seem and require considerably more time and resources than needed to ask the ethnocentric question(s) which assume constancy of core and associated features of mental disorder. For example, Manson, Shore, et al. and Bloom (1985) found that the Schedule for Affective Disorders and Schizophrenia (SADS-L, Endicott & Spitzer 1978) was reliable when (1) it was administered by clinicians familiar with Indian patients; and (2) it was modified so that a more complete history of physical illness and personal loses was gathered. It is not entirely clear what knowledge is possessed by a clinician "familiar with Indian patients," so that he or she can make a better diagnosis than a clinician who has less experience or familiarity with Indians. Indeed, would a clinician familiar with Flathead tribal

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

417

culture be as good a diagnostician among the Nooksack or the Navajo? Is it the daunting spectacle of infinite variations in culturally determined symptom presentations and the complexities of nomenclatures to represent adequately such variations that encourages clinicians to resort to assumptions of cultural invariance in core symptoms while allowing for superficial variations in symptom expression? Assessment measures, especially self-reports, tend to demand that respondents can make clear discriminations between subjective anxiety and depression. Patients are expected to be able to provide valid responses based on knowing different signs and symptoms in themselves for anxiety and depression separately. Such distinctions may not be possible for many, if not most, people and take on added complexity when cultural factors are considered. Where they perceive anxiety and depression as a unitary construct they will tend to reply randomly or reply in accordance with which ever of the two constructs the individual feels is predominant (Watson & Clark 1984). We raise the question whether or not this is true for those working with Indian and Native populations and point to the considerable evidence that the separation of thinking and feeling states is not as distinct in non-Western cultures. This question is not to be regarded as a deficiency in psychological sophistication for enumerating and compartmentalizing negative affective symptoms, but rather as a cultural alternative to the view of emotions as internalized states. Lutz (1985) used ethnopsychological data from her own work with the Ifaluk of Micronesia, as well as other sources, to show that emotions may be "grouped with moral values rather than with internal disruptions, they may be linked with logical thoughts as much or more than internal conflict, and they may be seen as characteristics of situations or relationships rather than as property of individuals" (p. 91). The descriptions of emotional differentiation related to affective disorders may be considerably greater in cultures which place a high value on social relationships and kinship bonds as opposed to individualistic cultures which focus on the use of introspection by a single person to identify and describe troubling emotional states. Both the classification schema of DSMIII-R and the structured interview methods that are used to diagnose psychiatric disorders using this schema are clearly designed for patients in the latter cultural category. The items of an assessment instrument should reflect the construct in which we are interested. If personality is our interest, then the instrument should attempt to systematically gather data on personality; or if the focus of our study is anxiety, then that construct should be measured. If we believe that depression is based on loss and anxiety on the threat of loss, then an instrument that purports to make a differential diagnosis should have questions related to loss and threat of loss. This statement is no more that content validity. If our construct is the objective, but atheoretic, diagnostic criteria of the DSM-III, then

418

JACK D. MASER AND NORMAN DINGES

the items comprising the instrument should reflect those criteria. Epidemiologic studies that use the Diagnostic Interview Schedule (DIS) and clinical studies that use the SADS or Scheduled Clinical Interview for DSM-III-R (SCID) or Anxiety Disorder Interview Schedule (ADIS) or the Structured Interview for the DSM-III Personality Disorders (SID-P) or most other clinical interviews should realize that these instruments are designed to reach a diagnosis by asking questions related to the diagnostic criteria of DSM-III or DSM-III-R. They will not assess strengths that the patient may possess, nor will they further characterize the patient beyond the criteria of the DSM. Nor will they necessarily adequately reflect the correspondence or lack thereof between symptom severity and functional impairment, which may be crucially important in adequate treatment planning for culturally different patients. At what point should we ask, "How is this construct influenced by cultural factors? Does loss have different meanings and different modes of expression in different cultures? Are we assessing those differences properly. Do our objectively defined diagnostic criteria need fine-tuning or does consideration of cultural factors suggest a paradigm shift in the approach taken to defining psychopathological constructs?" Over the years there has been a bootstrapping relationship between the nomenclature and various assessment tools by which the instruments provided data that changed the nomenclature. In light of these changes in the DSM, the instruments were further modified, and after a further period of data collection, the nomenclature was modified again. All of this activity seems to have occurred in the absence of any substantial input from those interested in crosscultural psychiatry. Future efforts would do well to heed the issues raised by cross-cultural methodology, not only for the diagnosis of depression, as illustrated by Good in this Issue, but for other disorders as well. Thus, problems of normative uncertainty, centricultural bias, indeterminacy of meaning, narrative context, and category validity all need to be taken into account in future epidemiological and clinical studies of psychiatric disorders (Jenkins, Kleinman and Good 1991; Good and Good 1986).

FUTURE DIRECTIONS Until demonstrated otherwise, perhaps we should proceed in classical research fashion to rigorously test the following null hypothesis: There are no differences in the core symptoms in a DSModefined disorder between the population at large and the cultural group under study. Unfortunately, there is a considerable a priori probability that cultural differences will be found, but that it will not be possible to determine which of the many ambient variables included under the rubric of "culture" are responsible for observed differences. Since we have

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

419

emphasized the importance of cultural differences in the assessment and diagnosis of mental disorders, it is perhaps time to formulate specific, directional hypotheses informed by ethnographic data about explanatory belief models regarding mental disorder. It would seem timely to test the role of cultural factors by predicting and verifying specific relationships between cultural beliefs and mental disorders at the level of descriptive psychiatry, if not etiology. What is needed are testable paradigms and collaboration among multiple sites. One suggestion that we considered was whether the field of cross-cultural clinical studies would be well served by constructing a diagnostic manual of its own. Call it the DSM-XC, for cross-cultural. The DSM-XC would include diagnostic criteria from the current DSM edition as well as criteria peculiar to a subculture. The network of active researchers involved with American Indian and Alaska Native populations is sufficiently small so that the National Center in Denver, Colorado, could coordinate such a project. Publications would report the standard DSM diagnosis as well as those of the -XC "edition". This consensually agreed upon procedure may help improve replication across samples, in the same manner in which the DSM-III did in the larger community of clinical researchers; and it would demonstrate the usefulness of cross-cultural factors to the designers of DSM-IV, ICD-IO and even later editions of these nomenclatures. An alternative suggestion involves using axes 4 and 5 of the current DSM-IIIR classification, both of which axes are now defined in global terms and crudely assessed, as a means of refining the contextualization of important aspects of the existing diagnostic framework. This approach would build on Fabrega's (1982) theory of illness/self conceptualization as an additional axis for the multiaxial system of DSM-III-R. Fabrega points out that such an axis, which focuses on individual definitions of illness and well-being, as well as self and behavior, all influence key parameters of psychiatric disorder. The current DSM-III-R axis 4, which focuses on psychosocial stressors, seems particularly appropriate for elaboration into the cultural domain of diagnosis. Axis 5, which focuses on global assessment of functioning, also holds considerable promise for expanding our understanding of cultural influences. However, in order to fulfill this promise, Axis 5 needs to be focused on better assessment of the coping choices and mechanisms which influence the duration and course of psychiatric disorder. For example, Vitaliano et al. (1987) illustrate the value of including coping measures in the diagnostic process by showing that coping processes provide a useful index of illness behavior. They found that coping measures distinguished better between panic disorder patients with multiple phobias and those without than did a measure of distress. The blueprint for DSM-IV has already been drawn, and the bricks and mortar are already ordered, so there is little possibility that the content and assessment procedures for axes 4 and 5 will

420

JACK D. MASER AND NORMAN DINGES

be altered significantly. However, planning for the design and content of later editions might benefit from consideration of ways to use these axes in operationalizing the cultural dimension of psychiatric diagnosis.

Summary of Papers Byron Good, Editor of Culture, Medicine and Psychiatry, places these papers in perspective not only for readers of this Journal, but for the broader readership in anthropology, cross-cultural studies and social influences in medicine. He spells out the importance of accounting for culture in clinical diagnoses and the types of problems that occur when this is not done. A particularly interesting, but controversial, point is that the DSM-III-R casebook is culturally biased and has had a major influence on diagnosticians. While we agree that the document is culturally biased, we believe that it reflects the bias of the DSM editions and has had little influence on its own. Theresa O'Nell's paper takes on the assumption that depression, substance abuse and suicide "are alternative, perhaps progressive, and perhaps sex-typed expressions of demoralization." She suggests examining this assumption by studying the relationships among these clinical conditions in culturally diverse populations. She begins with adult members of the Salish and Pend d'Oreilles tribes at the Flathead Reservation in Montana. Fifty unstructured, unscheduled interviews were conducted, the content of which allowed the author to reach a DSM-III diagnosis on 20 Flatheads who had a "depressive experience." Depression in this paper is treated with a stronger anthropological/ethnocentric approach than other papers in this collection, and follows directly from her outstanding critical review of psychiatric studies among American Indians and Alaska Natives (O'Nell 1989). Comorbid psychiatric symptoms are not limited to adults, as Sack, Beiser, Phillips, and Baker-Brown describe in their paper on children in the Flower of Two Soils project. Psychiatric diagnosis in children is less reliable than that in adults, and cultural issues further complicate the matter for most clinicians. The Flower of Two Soils project was designed to study an apparent deterioration in academic achievement coincident with an increase in the use of mental health treatment facilities. The disorders of interest are depression and conduct disorder, although the authors also report on suicidal symptomatology. The data are important because of their longitudinal and prospective methodology, attributes which are relatively rare in studies of American Indians. Following on earlier reports (Dinges and Duong-Tran 1991; Dinges and Joos 1988; Dinges, Jones and Duong-Tran 1987), Dinges and Duong-Tran here look at the co-occurrence of depression and substance abuse accompanied by the high frequency of suicidality in American Indian/Alaska Native adolescents. Both

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

421

depression and substance abuse separately are found to include a suicidality component (ideation or recent attempt), but more remarkable is the high frequency of comorbidity with suicidality. As with all other reports in this special issue, selection factors present problems for interpretation and generalizasion. Particularly interesting to students of life events and psychiatric illness (e.g. See Monroe, 1990), the authors find that stressful life events change with the type and severity of comorbidity. The performance of the CES-D (Center for Epidemiologic Studies - Depression Scale, Radloff 1977) in a sample of 120 Northwest Coast American Indians is examined in the paper by Somervell, Beals, Kinzie, Boehnlein, Leung and Manson. Somatic complaints and emotional distress are not well differentiated in the instrument for this sample. The weak, positive correlation noted for alcoholism and depression raises a problem of sampling for many psychiatric epidemiologic studies of American Indians and ways are suggested to resolve the problem. Westermeyer, Neider and Westermeyer describe 100 American Indian patients (primarily Chippewa, but including Sioux, Cree, Seneca, Kiowa and Blackfoot) diagnosed as having a psychoactive substance use disorder. This sample was also found to have a wide range of other clinical problems including organic mental disorders, major depression, panic and social phobia, schizophrenia, conduct, and sexual disorders. Although subjects had good access to local treatment facilities, there was little long-term benefit. Southern Cheyenne living in Western Oklahoma are the subjects in Brown, Albaugh, Robin, Goodson and others. The focus is on the heritable degree of risk for alcoholism and/or substance abuse. Double abuse (alcoholism and abuse of other substances) was highly prevalent, although there was a substantial difference between male and female alcoholics. Age of onset is found to be an important variable and a significant one to study since in caucasians early onset is considered an indication of genetic vulnerability. The relative contributions of genetic and environmental variables remain indirect and controversial. Boehnlein, Kinzie, Leung, Johnson, and Shore describe a 19 year outcome of physical and psychiatric illness in 100 Pacific Northwest Indians. Diagnoses related to the cardiovascular system, which were relatively rare in 1969 were much more prevalent in 1988. The course of alcoholism was found to be a complicated one, and related to alcoholism, the onset of depression affected many in the sample sometime during the 19 year interval. Comorbid psychopathology has treatment implications, and these are discussed in the paper by Walker, Lambert, Walker and Kivlahan. The data come from a community sample of 290 urban American Indian families in the Pacific Northwest. Because comorbid psychiatric conditions are not usually assesssed systematically within the Indian health care system, treatment is likely to be prolonged and often ineffective. Also important for planning treatment

422

JACK D. MASER AND NORMAN DINGES

strategy is the assessment o f cultural identity, a skill possessed by few clinicians. W e know from experience that numerous obstacles to mental health services for ethnic minorities exist. Thresholds o f increasing severity for psychiatric disorder have to be breached by minority patients before there is a meaningful clinical encounter. The authors also addresss traditional approaches to healing and then turn to the difficult problem o f treating adolescents. O f interest to readers o f this Journal is that nearly all o f the papers collected in this issue consider the ethnocentric and geographic reasons that may contribute to the reported findings. Of particular importance is that most o f the reports use standardized psychiatric interviews, scheduled to the current nomenclature. This assessment method has the advantage o f linking diagnostic findings in these cultural groups to the larger psychiatric literature.

NOTES I The views expressed in this paper are those of the authors only, and do not necessarily reflect those of the National Institute of Mental Health. Reprints may be obtained by writing to Dr. Jack D. Maser, National Institute of Mental Health, Room 10C24, 5600 Fishers Lane, Rockville, Maryland 20857. 2 Attenders were Gerald L. Brown, Norman Dinges, Byron Good, Wayne Katon, J. David Kinzie, Peter Lewinsohn, Spero M. Manson, Jack D. Maser, Gordon Neligh, Scott H. Nelson, Theresa D. O'Nell, William H. Sack, James H. Shore, Phillip Somervell, R. Dale Walker, and Joseph Westermeyer.

REFERENCES American Psychiatric Association 1980 Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. Washington, D.C.: American Psychiatric Press. 1987 Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition Revised. Washington, D.C.: American Psychiatric Press. Bell, C. C., B. Shakoor, B. Thompson, D. Dew, E. Hughley, R. Mays, and K. ShorterGooden 1984 Prevalence of Isolated Sleep Paralysis in Black subjects. Journal of the National Medical Association 76: 501-508. Bell, C.C., D.D. Dixie-Bell, and B. Thompson 1986 Further Studies on the Prevalence of Isolated Sleep Paralysis in Black subjects. Journal of the National Medical Association 75: 649-659. Berkson, J. 1946 Limitations of the Application of Fourfold Table Analysis to Hospital Data. Biometric Bulletin 2: 47-53. Berry, J. and V. Kim 1988 Acculturation and Mental Health. In Health and Cross-cultural Psychology P. Dasen, J. Berry, and N. Sartorius (eds.), pp. 207-238. Newbury Park, CA: Sage. Boyd, J.H., J.D. Burke, E. Gruenberg, C.E. Holzer, III, D.S. Rae, L.K. George, M. Karno, R. Stoltzman, L. McEvoy, and G. Nestadt

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

423

1984 Exclusion Criteria of DSM-III. Archives of General Psychiatry 41: 983-989. Dinges, N.G., and Duong-Tran, Q. 1991 Suicide ideation and suicide attempt among American Indian and Alaska Native Boarding School Adolescents. In W. Sack, C. Duclof, and S. Manson (eds.), American Indian and Alaska Native Adolescent Suicide Research, Monograph Series of the National Center for American Indian and Alaska Native Mental Health Research, Volume 4. Dinges, N.G., Joos, S.K., and Duong-Tran, Q. 1987 Development and validation of a mental health screening measure for American Indian adolescents. Final report to the Mental Health Branch, Portland Area Office, U.S. Indian Health Service. Dinges, N.G., and Joos, S.K. 1988 Stress, coping, and health: Models of interaction for Indian and native populations. American Indian and Alaska Native Mental Health Research 1: 8-55. Endicott, J. and R.L. Spitzer 1978 A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry 35: 837--844. Everett, H.C. 1963 Sleep Paralysis in Medical Students. Journal of Nervous and Mental Diseases 136: 283-287. Fabrega, H. 1982 Culture and Psychiatric illness: Biomedical and Ethnomedical Aspects. In A. Marsella, and G. White (eds.), pp. 39--68. Cultural Conceptions of Mental Health and Therapy. Dordrecht, Holland: D. Reidel Publishing Co. Fabrega, H. 1987 Psychiatric Diagnosis: A Cultural Perspective. The Journal of Nervous and Mental Disease 175 (7): 383-394. Fabrega, H., Jr. 1990 A Plea for a Broader Ethnomedicine. Culture, Medicine and Psychiatry t4: 129-132. Feinstein, A.R. 1970 The pre-therapeutic classification of co-morbidity in chronic disease. Journal of Chronic Diseases 23: 455--468. Good, B.J. and M.-J.D. Good 1986 The Cultural Context of Diagnosis and Therapy: A View from Medical Anthropology. Mental Health Research & Practice in Minority Communities: Development of Culturally Sensitive Training Programs. In M.R. Miranda and H.H.L. Kitano (eds.), pp. 1-27. U.S. Department of Health and Human Services Publication No. (ADM) 86-1466. Washington, D.C.: U.S. Government Printing Office. Good, B.J. and A.M. Kleinman 1985 Culture and Anxiety: Cross-Cultural Evidence for the Patterning of Anxiety Disorders. In Anxiety and the Anxiety Disorders A.H. Tuma and J.D. Maser (eds.), pp. 297-323. Hillsdale, N.J.: Lawrence Erlbaum Associates. Goode, G.B. 1962 Sleep paralysis. Archives of Neurology 6: 228-234. Jenkins, J., Kleinman, A. and Good, B. 1990 Cross-cultural studies of depression. In J. Becker and A. Kleinman (eds.) Advances in Mood Disorder pp. 67-99. Hillsdale, N J: Lawrence Erlbaum Associates, Publishers. Jenkins, J., A. Kleinman, and B. Good 1991 Cross-cultural Studies of Depression. In J. Becker and A. Kleinman (eds.), Psychosocial Aspects of Depression, pp. 67-99. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.

424

JACK D. MASER AND NORMAN DINGES

Keane, T.M. and Wolfe, J. 1990 Comorbidity in post-traumatic stress disorder: An analysis of community and clinical studies. Journal of Applied Social Psychology 20 (21 pt. 1): 1776-1788. Kirmayer, L. 1991 The Place of Culture in Psychiatric Nosology: Taijin Kyofusho and DSM-III-R. The Journal of Nervous and Mental Disease 179 (1), 19-28. Levy, J., S. Kunitz and E. Henderson 1987 Hopi Deviance in Historical and Epidemiological Perspective. In Themes in ethnology and culture: Essays in honor of David F. Aberle. J. Jorgensen and L. Donald (eds.), Berkeley: Folklore Institute. Lock, M. 1987 DSM-III as a Culture-bound Construct: Commentary on Culture-bound Syndromes and International Disease Classification. Culture Medicine and Psychiatry, 11: 35-42. Lutz, K. 1985 Depression and translation of emotional worlds. In: Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder. A. Kleinman and B. Good, (eds.), 63-100 Berkeley, CA: U. of California Press. Manson, S.M., Shore, J.H. and Bloom, J.D. 1985 Depressive experiences in Indian communities: A challenge for psychiatric diagnosis and theory. In A. Kleinman and B. Good (eds.), Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder. Berkeley, CA: University of California Press. Maser, J.D. and C.R. Cloninger 1990 Comorbidity of Mood and Anxiety Disorders. Washington, D.C.: American Psychiatric Press. Maser, J.D., C. Kaelber and R.E. Weise 1991 International Use and Attitudes toward DSM-III and DSM-III-R: Growing Consensus in Psychiatric Classification. Journal of Abnormal Psychology 100 (3): 271-279. Monroe, S.M. 1990 Psychosocial Factors in Anxiety and Depression. In Comorbidity of Mood and Anxiety Disorders, J.D. Maser and C.R. Cloninger (eds.), pp. 463-497. Washington, D.C.: American Psychiatric Press. Neal, A.M. and S.M. Turner 1991 Anxiety Disorders Research With African Americans: Current Status. Psychological Bulletin 109 (3): 40(0-410. Ness, R.C. 1978 The Old Hag Phenomenon as Sleep Paralysis: a Biocultural Interpretation. Culture, Medicine and Psychiatry 2:15-39. O'Nell, T.D. 1989 Psychiatric Investigations among American Indians and Alaska Natives: A Critical Review. Culture, Medicine and Psychiatry 13:51-87. Radloff, L.S. 1977 The CES-D scale: a self-report depressive scale for research in the general population. Journal of Applied Psychological Measurement 1: 385-401. Regier, D.A., M. Farmer, D. Rae, B.Z. Locke, S. Keith, L. Judd, and F. Goodwin 1990 Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse: Results from the Epidemiological Catchment Area (ECA) Study. Journal of the American Medical Association 264 (19): 2511-2518. Robins, L.N., J.E. Helzer, J. Croughan, and K.S. Ratcliff 1981 National Institute of Mental Health Diagnostic Interview Schedule. Archives of General Psychiatry 38: 381-389. Sturt, E. 1981 Hierarchical Patterns in the Distribution of Psychiatric Symptom. Psychiatric

INTRODUCTION TO PSYCHIATRIC COMORBIDITY

425

Medicine 11: 783-794. Tyrer, P., J. Alexander, M. Remington, and P. Riley 1987 Relationship between Neurotic Symptoms and Neurotic Diagnosis: A Longitudinal Study. Journal of Affective Disorders 13: 13-21. Vitaliano, P., P. Katon, J. Russo, R. Maiuro, K. Anderson and M. Jones 1987 Coping as an Index of Illness Behavior in Panic Disorder. The Journal of Nervous and Mental Disease 179 (2): 78-84. Watson, D. and L.A. Clark 1984 Negative Affectivity: The Disposition to Experience Aversive Emotional States. Psychological Bulletin 96: 465--490. World Health Organization 1977 International Classification of Diseases, Injuries, and Causes of Death (9th edition). Geneva: World Health Organization.

National Institute of Mental Health Rockville, MD 20857 and University of Alaska-Fairbanks