Opinion Editorial
Most service delivery planning is based on an estimate of point (or annual) prevalence to help with resource allocation. Trends depend on multiple repeated measures to identify significant changes in prevalence over time. For these purposes, cross-sectional studies still have extraordinary value, and we will not stop conducting them. However, Takayanagi and colleagues remind us quite clearly that a cross-sectional study design should not be applied indiscriminately. Overall, the findings from this study are an important reminder to be quite cautious in using lifetime prevalence rates generated from a single cross-sectional study. At a minimum, we should see the lifetime prevalence estimates generated from cross-sectional studies as the low estimates and as a starting point for inquiry rather than as an accurate depiction of the true burden of disease. ARTICLE INFORMATION Author Affiliations: National Institute on Drug Abuse, Bethesda, Maryland. Corresponding Author: Wilson M. Compton, MD, MPE, National Institute on Drug Abuse, 6001 Executive Blvd, MSC 9589, Bethesda, MD 20892 ([email protected]). Published Online: January 8, 2014. doi:10.1001/jamapsychiatry.2013.4111. Conflict of Interest Disclosures: Dr Compton reports stock holdings in Pfizer, General Electric, and 3M. No other disclosures were reported. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the National Institute on Drug
We congratulate Takayanagi and colleagues on identifying an important limitation in survey methods as applied to psychiatric illnesses where stronger methods that provide multiple assessments across time and/or from different informants are suggested. The more we learn about psychiatric conditions, the greater the need is for external validators and endophenotypes.5 Only when we know the underlying markers of disease and enhance clinical appraisal with genetic or neuroscience measures will we be able to completely accurately understand the prevalence of these conditions. Until such a day when these markers and measures are available, we will rely on multiple sources of information that triangulate on results as the next best alternative for confirming our insights and improving our knowledge.
Abuse, the National Institutes of Health, or the US Department of Health and Human Services. REFERENCES 1. Takayanagi Y, Spira AP, Roth KB, Gallo JJ, Eaton WW, Mojtabai R. Accuracy of reports of lifetime mental and physical disorders: results from the Baltimore Epidemiological Catchment Area Study [published online January 8, 2013]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.3579. 2. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39(1):28-38.
3. Copeland W, Shanahan L, Costello EJ, Angold A. Cumulative prevalence of psychiatric disorders by young adulthood: a prospective cohort analysis from the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry. 2011;50(3):252-261. 4. Moffitt TE, Caspi A, Taylor A, et al. How common are common mental disorders? evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2010;40(6):899-909. 5. Jupp B, Dalley JW. Behavioral endophenotypes of drug addiction: etiological insights from neuroimaging studies [published online June 10, 2013]. Neuropharmacology. doi:10.1016 /j.neuropharm.2013.05.041.
Mortality in Patients With Traumatic Brain Injury Robert G. Robinson, MD
The current issue of JAMA Psychiatry includes an important article on premature mortality among patients with traumatic brain injury (TBI) in Sweden between 1969 and 2009.1 According to the study by Fazel et al,1 among 218 300 patients with a Related article page 326 TBI compared with age- and sex-matched controls without brain injury (10 to 1 match, n = 2 163 190) and unaffected siblings of TBI patients (n = 150 513), there was a 3-fold increased odds of all-cause mortality, adjusted for sociodemographic confounders (adjusted odds ratio [aOR], 3.2; 95% CI, 3.0-3.4), among patients who survived at least 6 months after TBI compared with general population controls or unaffected siblings (aOR, 2.6; 95% CI, 2.3-2.8). The increased rates of mortality were related to injury (aOR, 4.3; 95% CI, 3.8-4.8), assault (aOR, 3.9; 95% CI, 2.75.7), or suicide (aOR, 3.3; 95% CI, 2.9-3.7). A major strength of this study, which used national Swedish patient registry data, was the statistical power derived from the large database. This database allowed the authors to examine, in detail, causes of early mortality when the overall frequency of premature mortality was relatively small. Among the 218 300 patients with TBI, premature death, which occurred after 6 234
months following the TBI and before 56 years of age, constituted only 2378 (1.1%) of the TBI cases. Furthermore, the causes of mortality, which include multiple physical illnesses and external causes, such as motor vehicle collisions, other injuries, suicide, and assault, were compared with controls and examined in detail. Consequently, this study had the power to compare death rates in a small portion of the population. External causes of mortality constituted almost half (48.6%) of the premature deaths compared with physical disorders, such as neoplasms, which caused premature death in 11.1% of the 2378 cases. Traumatic brain injury has become a topic of public interest in the United States within the past 10 years because of the common causes of brain injury, such as combat, sports (particularly football), and unprovoked assaults. These potentially preventable injuries have attracted the attention of the military leadership, the families of injured people, politicians, sports organizations (particularly the National Football League), psychiatrists, psychologists, attorneys, and others. The pathologic features, symptoms, and course of TBI can be widely different depending on the cause, type (eg, contusion, shear, and intracranial bleed), or severity of the injury. Many of the US soldiers from the Iraq and Afghanistan wars experienced TBI from shock waves
JAMA Psychiatry March 2014 Volume 71, Number 3
Copyright 2014 American Medical Association. All rights reserved.
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Editorial Opinion
generated by improvised explosive devices,2 whereas others incurred penetrating brain injury, contusions of the brain, or bleeds in or around the brain of differing severities. Some of the major limitations of the current study are that the cause of the TBI could not be specified (the type of TBI could be identified in
Most service delivery planning is based on an estimate of point (or annual) prevalence to help with resource allocation. Trends depend on multiple repeated measures to identify significant changes in prevalence over time. For these purposes, cross-sectional studies still have extraordinary value, and we will not stop conducting them. However, Takayanagi and colleagues remind us quite clearly that a cross-sectional study design should not be applied indiscriminately. Overall, the findings from this study are an important reminder to be quite cautious in using lifetime prevalence rates generated from a single cross-sectional study. At a minimum, we should see the lifetime prevalence estimates generated from cross-sectional studies as the low estimates and as a starting point for inquiry rather than as an accurate depiction of the true burden of disease. ARTICLE INFORMATION Author Affiliations: National Institute on Drug Abuse, Bethesda, Maryland. Corresponding Author: Wilson M. Compton, MD, MPE, National Institute on Drug Abuse, 6001 Executive Blvd, MSC 9589, Bethesda, MD 20892 ([email protected]). Published Online: January 8, 2014. doi:10.1001/jamapsychiatry.2013.4111. Conflict of Interest Disclosures: Dr Compton reports stock holdings in Pfizer, General Electric, and 3M. No other disclosures were reported. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the National Institute on Drug
We congratulate Takayanagi and colleagues on identifying an important limitation in survey methods as applied to psychiatric illnesses where stronger methods that provide multiple assessments across time and/or from different informants are suggested. The more we learn about psychiatric conditions, the greater the need is for external validators and endophenotypes.5 Only when we know the underlying markers of disease and enhance clinical appraisal with genetic or neuroscience measures will we be able to completely accurately understand the prevalence of these conditions. Until such a day when these markers and measures are available, we will rely on multiple sources of information that triangulate on results as the next best alternative for confirming our insights and improving our knowledge.
Abuse, the National Institutes of Health, or the US Department of Health and Human Services. REFERENCES 1. Takayanagi Y, Spira AP, Roth KB, Gallo JJ, Eaton WW, Mojtabai R. Accuracy of reports of lifetime mental and physical disorders: results from the Baltimore Epidemiological Catchment Area Study [published online January 8, 2013]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.3579. 2. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39(1):28-38.
3. Copeland W, Shanahan L, Costello EJ, Angold A. Cumulative prevalence of psychiatric disorders by young adulthood: a prospective cohort analysis from the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry. 2011;50(3):252-261. 4. Moffitt TE, Caspi A, Taylor A, et al. How common are common mental disorders? evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2010;40(6):899-909. 5. Jupp B, Dalley JW. Behavioral endophenotypes of drug addiction: etiological insights from neuroimaging studies [published online June 10, 2013]. Neuropharmacology. doi:10.1016 /j.neuropharm.2013.05.041.
Mortality in Patients With Traumatic Brain Injury Robert G. Robinson, MD
The current issue of JAMA Psychiatry includes an important article on premature mortality among patients with traumatic brain injury (TBI) in Sweden between 1969 and 2009.1 According to the study by Fazel et al,1 among 218 300 patients with a Related article page 326 TBI compared with age- and sex-matched controls without brain injury (10 to 1 match, n = 2 163 190) and unaffected siblings of TBI patients (n = 150 513), there was a 3-fold increased odds of all-cause mortality, adjusted for sociodemographic confounders (adjusted odds ratio [aOR], 3.2; 95% CI, 3.0-3.4), among patients who survived at least 6 months after TBI compared with general population controls or unaffected siblings (aOR, 2.6; 95% CI, 2.3-2.8). The increased rates of mortality were related to injury (aOR, 4.3; 95% CI, 3.8-4.8), assault (aOR, 3.9; 95% CI, 2.75.7), or suicide (aOR, 3.3; 95% CI, 2.9-3.7). A major strength of this study, which used national Swedish patient registry data, was the statistical power derived from the large database. This database allowed the authors to examine, in detail, causes of early mortality when the overall frequency of premature mortality was relatively small. Among the 218 300 patients with TBI, premature death, which occurred after 6 234
months following the TBI and before 56 years of age, constituted only 2378 (1.1%) of the TBI cases. Furthermore, the causes of mortality, which include multiple physical illnesses and external causes, such as motor vehicle collisions, other injuries, suicide, and assault, were compared with controls and examined in detail. Consequently, this study had the power to compare death rates in a small portion of the population. External causes of mortality constituted almost half (48.6%) of the premature deaths compared with physical disorders, such as neoplasms, which caused premature death in 11.1% of the 2378 cases. Traumatic brain injury has become a topic of public interest in the United States within the past 10 years because of the common causes of brain injury, such as combat, sports (particularly football), and unprovoked assaults. These potentially preventable injuries have attracted the attention of the military leadership, the families of injured people, politicians, sports organizations (particularly the National Football League), psychiatrists, psychologists, attorneys, and others. The pathologic features, symptoms, and course of TBI can be widely different depending on the cause, type (eg, contusion, shear, and intracranial bleed), or severity of the injury. Many of the US soldiers from the Iraq and Afghanistan wars experienced TBI from shock waves
JAMA Psychiatry March 2014 Volume 71, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Fudan University User on 05/13/2015
jamapsychiatry.com
Editorial Opinion
generated by improvised explosive devices,2 whereas others incurred penetrating brain injury, contusions of the brain, or bleeds in or around the brain of differing severities. Some of the major limitations of the current study are that the cause of the TBI could not be specified (the type of TBI could be identified in
