characteristics i^ME '-Ness in north-east
of mental
Scotland by George Innes, M.D., D.P.H.*
report of Phis is the of mental
an
social, clinical and treatment data were collected from all new adult patients resident in the North East of Scotland who were referred for psychiatric advice or treatment. The information collected on each patient consisted of items such as age, marital status, address, occupation, education, place of birth, diagnosis, type and duration of treatA new patient was defined as ment. one who had not consulted a psychiatrist
epidemiological
illness in North^Cotlan^- Epidemiology Is the stuH of the distribution of disease in populations, and of the factors eHt th influence this distribution. In studies of a disease, the goal is to find which groups in the being examined are suscepte, to.that disease. Having found these isk groups, the next step is to cover the factors which make them nerable. This stage of the investigatjQ may a8ain be epidemiological in or, more likely, it will be clinical, mical or bacteriological. The fin i .steP is prevention of the disease by the factors found to be causative. were at first conCe P^emiologists infectious diseases, but st ?f these have now reached the of prevention. With other dissuch as cancer of the lung, risk groups have been identified that ?f .second stage of investigation, js n discovering the causative factors, Pro8ress. In the case of mental ill however, we are still at the stage entifying the high-risk groups.
study
t
J"ri ^'Qemiological pQst juration dif
during
nat1 u?e,
prin8
ea8e
study
is start-latr^cpointdisorder for an
lr}8
of large
num-
treatment for
the
obvious
epidemiological
of mental illness. ^ligation lt" its natural geographic
dari
psychiatric treatment. The high proportion
of females is similar to that found for mental hospital admissions both in Scotland and England, but differs in an, as yet, inexplicable way from mental hospital admissions in the United States, where more males than females are seen. Although there is in this country at the present time no completely satisfactory method of social classification, previous studies have been almost unanimous in finding that mental illness is more frequent in the lower social classes. Contrary to this finding, it was
boun-
population of approximately ha[fes an.d covered by the m^i?n, the
Nortk
area
Scotland Regional Hosis ideal for carrying out such a st yIn addition, the psychiatric int JCes ?f the Region are extremely well being centred round the in tu ?nic and the two mental hospitals
P'tal
^
ast
^?ard
servU
Rossr^.'
Aberdeen geUring for
area.
1960,
Heanf
>
^search
a
period
of one year,
Fellow, Department of Mental
University of Aberdeen.
91 :
period.
Only a few of the findings can be discussed in this short paper. Altogether 2,103 patients were referred during the year of the study: 1,240 females and 863 males. These total referrals represent 5.7 persons per thousand adult population, with a sex distribution of 6.2 patients per thousand females and 5.0 patients per thousand males in the population. Three-quarters of the patients referred had not had previous
OfiH8'
of
one-year
Results
.
bers c?mPrehensive study p.ersons receiving Psv
previous
study.
h3. aA
Ascription
a
Inclusion of all mental hospital admissions, all out-patient referrals and all those seen by psychiatrists in geneial hospitals, on domiciliary visits and in private practice, ensured complete coverage of all regional psychiatric services. Hospitals outside the region were checked, and any North-East residents were discovered for inclusion in the
found in the present study that the highest referral rate was from the upper social class, the professional group. The main increase in this class was in those diagnosed as suffering from a neurosis, suggesting that the higher social classes, in this area at any rate, come forward more readily than others for the treatment of minor mental disorders. Almost half the population of the region live in the city of Aberdeen. Referrals from the city were found, for both sexes, to be significantly higher than referrals from the rural area. However, the main psychiatric services are in the city, and it could be argued that nearness to the service was an important factor in determining whether patients come forward for treatment. This is not the complete answer to the difference, however. Comparison of the city of Aberdeen and the three next largest towns in the area (populations of approximately 10,000 each) shows referral rates which are almost identical. Two of these towns are at the periphery of the region, and over forty miles from the nearest psychiatric hospital. The high referral rates would thus seem to be associated in some way with urban life, and not connected with distance from service. One factor which does emerge very clearly, however, is that the rates of people with severe disorder (psychoses) is very similar for both town and country. The excess of referrals from the towns is taken up by a larger number of referrals of less severe illness. The patients who were identified during this study are still being followed through all their contacts with the psychiatric service, to obtain information about the natural history of mental illness. In addition, a psychiatric caseregister was set up in the Region, beginning on 1st January, 1963, to bring together details of a patient's contacts with the psychiatric services in the area over a long period of time. This register will facilitate further epidemiological, clinical and operational research. Taken by themselves, all the findings described above would indicate variations in the numbers of patients suffering from mental illness, according to the 92
of their residence and according occupation. But, since the stuj was one of "treated mental this conclusion would only be valid ? patients suffering from mental received treatment from a psychiatr' j All the available evidence suggests w there are in the population a number of persons suffering fr? mental illness who do not specialist treatment. Studies in practice indicate that of every patients seen, about 100 are sufferl," from psychiatric illness. But the stu described shows that in this af area
their
illn^sJ iUn?(
j.af?
rece'ai
gen^v)
just only 6 out of every 1,000 are referred the psychiatric services in any one ye ]
There is no doubt that general titioners treat a great deal of psychiatric illness, without referral the patient to a specialist. nt In spite of the expansion of out-pa*1 facilities in the past 30 years and, rfl recently, the development of Day ^ and domiciliary treatment there is no evidence that the psychia services are nearing saturation Thus, in this region, the opening oi Ross Clinic, a 40-bedded 3 intensive care unit with about ^ admissions annually, did not dim111Q the number of admissions to the local mental hospitals. The Ross d1 patients seemed to come from ,s? untapped reserve in the communis j Mental illness presents special basic problems of definition. There no biochemical or bacteriological which will differentiate the from the rest of the population. ^ epidemiologist, if he is to arrive accurate figures for the incidence mental disorder, has to find some of identifying untreated illness. ^ cgS he does, it is possible that the diffefen etl between the social classes and urban and rural areas, described eaf -ng will be found to be due, not to differ ^ rates of illness in these groups, bu differing treated/untreated ratios. rS
P.ror .
serY1(^
P*?1^ short-te^ ^
tej|f
mentally
^
bet^.^
Although approximately three-quar ^
of patients in this area are referred to psychiatric services by general P j5 titioners, the request for assistant jf usually initiated by the patient h^m or a close relative. Any definiti?n
^
l
Seated mental illness must therefore related to the sorts of community ?cesses which go on in identifying a rson as mentally ill.
There is evidence suggest that the criteria used by the 'firnunity to define psychiatric illness e very different from those regarded important by the psychiatrist. In disturbed relationships Viv Wor
of mental
Scotland by George Innes, M.D., D.P.H.*
report of Phis is the of mental
an
social, clinical and treatment data were collected from all new adult patients resident in the North East of Scotland who were referred for psychiatric advice or treatment. The information collected on each patient consisted of items such as age, marital status, address, occupation, education, place of birth, diagnosis, type and duration of treatA new patient was defined as ment. one who had not consulted a psychiatrist
epidemiological
illness in North^Cotlan^- Epidemiology Is the stuH of the distribution of disease in populations, and of the factors eHt th influence this distribution. In studies of a disease, the goal is to find which groups in the being examined are suscepte, to.that disease. Having found these isk groups, the next step is to cover the factors which make them nerable. This stage of the investigatjQ may a8ain be epidemiological in or, more likely, it will be clinical, mical or bacteriological. The fin i .steP is prevention of the disease by the factors found to be causative. were at first conCe P^emiologists infectious diseases, but st ?f these have now reached the of prevention. With other dissuch as cancer of the lung, risk groups have been identified that ?f .second stage of investigation, js n discovering the causative factors, Pro8ress. In the case of mental ill however, we are still at the stage entifying the high-risk groups.
study
t
J"ri ^'Qemiological pQst juration dif
during
nat1 u?e,
prin8
ea8e
study
is start-latr^cpointdisorder for an
lr}8
of large
num-
treatment for
the
obvious
epidemiological
of mental illness. ^ligation lt" its natural geographic
dari
psychiatric treatment. The high proportion
of females is similar to that found for mental hospital admissions both in Scotland and England, but differs in an, as yet, inexplicable way from mental hospital admissions in the United States, where more males than females are seen. Although there is in this country at the present time no completely satisfactory method of social classification, previous studies have been almost unanimous in finding that mental illness is more frequent in the lower social classes. Contrary to this finding, it was
boun-
population of approximately ha[fes an.d covered by the m^i?n, the
Nortk
area
Scotland Regional Hosis ideal for carrying out such a st yIn addition, the psychiatric int JCes ?f the Region are extremely well being centred round the in tu ?nic and the two mental hospitals
P'tal
^
ast
^?ard
servU
Rossr^.'
Aberdeen geUring for
area.
1960,
Heanf
>
^search
a
period
of one year,
Fellow, Department of Mental
University of Aberdeen.
91 :
period.
Only a few of the findings can be discussed in this short paper. Altogether 2,103 patients were referred during the year of the study: 1,240 females and 863 males. These total referrals represent 5.7 persons per thousand adult population, with a sex distribution of 6.2 patients per thousand females and 5.0 patients per thousand males in the population. Three-quarters of the patients referred had not had previous
OfiH8'
of
one-year
Results
.
bers c?mPrehensive study p.ersons receiving Psv
previous
study.
h3. aA
Ascription
a
Inclusion of all mental hospital admissions, all out-patient referrals and all those seen by psychiatrists in geneial hospitals, on domiciliary visits and in private practice, ensured complete coverage of all regional psychiatric services. Hospitals outside the region were checked, and any North-East residents were discovered for inclusion in the
found in the present study that the highest referral rate was from the upper social class, the professional group. The main increase in this class was in those diagnosed as suffering from a neurosis, suggesting that the higher social classes, in this area at any rate, come forward more readily than others for the treatment of minor mental disorders. Almost half the population of the region live in the city of Aberdeen. Referrals from the city were found, for both sexes, to be significantly higher than referrals from the rural area. However, the main psychiatric services are in the city, and it could be argued that nearness to the service was an important factor in determining whether patients come forward for treatment. This is not the complete answer to the difference, however. Comparison of the city of Aberdeen and the three next largest towns in the area (populations of approximately 10,000 each) shows referral rates which are almost identical. Two of these towns are at the periphery of the region, and over forty miles from the nearest psychiatric hospital. The high referral rates would thus seem to be associated in some way with urban life, and not connected with distance from service. One factor which does emerge very clearly, however, is that the rates of people with severe disorder (psychoses) is very similar for both town and country. The excess of referrals from the towns is taken up by a larger number of referrals of less severe illness. The patients who were identified during this study are still being followed through all their contacts with the psychiatric service, to obtain information about the natural history of mental illness. In addition, a psychiatric caseregister was set up in the Region, beginning on 1st January, 1963, to bring together details of a patient's contacts with the psychiatric services in the area over a long period of time. This register will facilitate further epidemiological, clinical and operational research. Taken by themselves, all the findings described above would indicate variations in the numbers of patients suffering from mental illness, according to the 92
of their residence and according occupation. But, since the stuj was one of "treated mental this conclusion would only be valid ? patients suffering from mental received treatment from a psychiatr' j All the available evidence suggests w there are in the population a number of persons suffering fr? mental illness who do not specialist treatment. Studies in practice indicate that of every patients seen, about 100 are sufferl," from psychiatric illness. But the stu described shows that in this af area
their
illn^sJ iUn?(
j.af?
rece'ai
gen^v)
just only 6 out of every 1,000 are referred the psychiatric services in any one ye ]
There is no doubt that general titioners treat a great deal of psychiatric illness, without referral the patient to a specialist. nt In spite of the expansion of out-pa*1 facilities in the past 30 years and, rfl recently, the development of Day ^ and domiciliary treatment there is no evidence that the psychia services are nearing saturation Thus, in this region, the opening oi Ross Clinic, a 40-bedded 3 intensive care unit with about ^ admissions annually, did not dim111Q the number of admissions to the local mental hospitals. The Ross d1 patients seemed to come from ,s? untapped reserve in the communis j Mental illness presents special basic problems of definition. There no biochemical or bacteriological which will differentiate the from the rest of the population. ^ epidemiologist, if he is to arrive accurate figures for the incidence mental disorder, has to find some of identifying untreated illness. ^ cgS he does, it is possible that the diffefen etl between the social classes and urban and rural areas, described eaf -ng will be found to be due, not to differ ^ rates of illness in these groups, bu differing treated/untreated ratios. rS
P.ror .
serY1(^
P*?1^ short-te^ ^
tej|f
mentally
^
bet^.^
Although approximately three-quar ^
of patients in this area are referred to psychiatric services by general P j5 titioners, the request for assistant jf usually initiated by the patient h^m or a close relative. Any definiti?n
^
l
Seated mental illness must therefore related to the sorts of community ?cesses which go on in identifying a rson as mentally ill.
There is evidence suggest that the criteria used by the 'firnunity to define psychiatric illness e very different from those regarded important by the psychiatrist. In disturbed relationships Viv Wor
