Psychiatry has been, among medical disciplines, the one showing the highest conflict between a «positivist» model and the «hermeneutic» tradition. In particular, in recent years several authors have suggested that both the scientific method and a scientific mentality should be introduced in psychiatric practice and research. They claim that criteria like a strong correlation among clearly defined signs and symptoms, a high predictive value towards the outcome and therapeutical response, and a clearly defined relationship between the symptoms and etiology are necessary to accept a diagnositc entity. Since in the case of e.g. schizofrenia such requirements are not met, some authors even suggest that the concept of schizofrenia should be abandoned. The present paper aims to show that such problems are not unique to mental disease, but are common to several branches of medicine. For example, the definition and classification of cancer follow a «polythetic» criterion which is similar to the concept of «family resemblances». Also, diagnostic reproducibility is often low in other medical disciplines. The paper examines how such methodological problems could be dealt with using the tools of epidemiology.

Objectives - To present a comprehensive review of the studies assessing the frequency of PTSD in the general population, in clinical populations and among subjects at risk. Design - An extensive search was made using the Excerpta Medica Psychiatry CD-ROM 1980-1993 (October). Using post-traumatic stress disorder as a key word, a total of 1,057 papers published in this timespan were retrieved. A further search was made using the same key word with MEDLINE CD-ROM 1988-1993. A manual search was also performed for all issues of the Journal of Traumatic Stress. Results - A total of 135 studies meeting inclusion criteria were selected for this review. Almost two thirds (n = 86, 64%) of these studies were carried out in the United States; only 8 (6%) studies have been carried out in developed countries. The sample size ranges from a low of 11 subjects up to a high of 22,463 subjects. The mean sample size is 500 and the median is 108. In terms of assessment methods, in one third (n = 45, 33%) of the studies the investigators used a PTSD symptom checklist (either self- administered or administered by a clinician), based on DSM criteria, to generate a PTSD diagnosis. In more than in one third of the studies (n = 44, 33%) of the studies, a structured interview was administered (e.g., the DIS, the SCID, the SADS), while in the remaining surveys the diagnostic evaluation was based either on an un- structured clinical assessment or on the administration of other specific assessment instruments (e.g., M-PTSD, IES, SCL-90-R or others). In 77 studies (57%) the investigators based their assessment on DSM-III diagnostic criteria for PTSD, whereas in 55 studies (41 %) DSM-III-R criteria were employed. Prevalence rates are discussed separately for the different population groups. Conclusions - There has been a remarkable increase in the number and quality of epidemiological studies on PTSD over the past decade. A substantial amount of information is now available about the frequency of PTSD among different population groups and among at risk subjects, and about risk factors, common symptom patterns, and natural history of this disorder. However, a number of important limitations of these studies are to be noted and should be addressed by future research efforts.

Objective - After a review of recent developments in the economic evaluation of mental health care, the study described in this paper suggests a methodology for the measurement and evaluation of costs in the Italian psychiatric system. Method and results - To conduct such an evaluation it is necessary to identify all relevant services, collect data on patients' receipt or utilization of health services (direct costs) and other services and resources within the socio- economic system (indirect costs), and to attach monetary values for the costs. A detailed unit cost list (LICU) was constructed for facilities available at South-Verona Community Psychiatric Service (CPS), as well as in many other community-based psychiatric services in Italy. This list covers psychiatric services, other public and private health services, criminal justice services, voluntary organisations and self-help groups. The procedure for calculating costs in three of these facilities (hospital inpatient service, psychiatric outpatient service and rehabilitation groups) are described in this paper in detail. A new instrument (ICAP) was developed to collect the data required to calculate the costs of community care for individual patients. In order to check the applicability and comprehensibility of the instrument, and the time ne- eded for its administration, the ICAP was tested with five patients. Conclusions - It will be interesting to utilise ICAP and LICU in a larger sample. The methodology described here would provide the basis for epidemiologically-based studies, as well as exploration of the factors which predict cost differences (such as socio-demographic characteristics, diagnosis, psychiatric history, ecc). It is important to emphasise the insights for policy and practice which can flow for the merged examination of costs, needs and outcomes. This research is presently in progress in South-Verona.

Objectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.

This paper argues within the mental health services that people who are most disabled by mental illness, the severely mentally ill (SMI), should be afforded the highest priority, and that services should be provided in relation to need. For this to occur the priority groups need first to be defined. Second, if a service wishes to provide for all prevalent cases of people suffering from severe mental illness, then a systematic method of recording local information about these people is required, and this may draw upon information about patients who are in contact with health services, social services, family health services and who contact voluntary sector and other agencies. One approach to estimating the need for services for people with SMI is by using indicative norms for service requirements. Finally, managerial methods are proposed to monitor how far targeting services to the SMI occurs in clinical practice.

Objective - The aim of our research is to evaluate the prevalence of psychiatric illnesses by means of data collected at the Florence municipality community mental health services encompassing all hospital and extramural activities, providing the same kind of information given by Psychiatric Case Register (PCR) covered areas. Design - It has been carried out a one week prevalence assessment through a cross-sectional analysis of clinical records gathered by psychiatric services of the submitted area. Population studied - The inquiry has considered the area of USL (Administative Local Authority of National Health Service) 10/A, 10/B, 10/C and 10/D, which constituite togheter with USL 10/E, the Florence municipality area. Results - Total and specific rates for diagnostic categories, sex and age reveal a large variability among the four considered USLs confirmed by standardized rates: the 10/A and 10/B USLs, that include the historic centre of Florence, present the highest standardized rates (10/A 207/100.000, 10/B 189/100.000), especially for the most severe disorders (Schizophrenia: 10/A 110/100.000, 10/B 87/100.000; Major Affective Disorders: 10/A 32/100.000, 10/B 38/100.000; Organic Psichosys: 10/A 6/100.000, 10/B 9/100.000). Conclusion - In the present study, the prevalence rate for all diagnoses for the whole area considered, is about 150.6/100.000, quite close to the estimate calculated in Verona-Sud (200/100.000). As to the different rates among USLs we have to bear in mind the development of the delivery care system, and the available clinical settings (on day hospital and residentials activities for long-term patients).

Aims -. To review the factors which are relevant for a correct evaluation of the costs of antidepressant drug treatment and to report the results of the studies on the efficacy, tollerability and costs of the most utilized antidepressants (tricyclics and SSRI). Methods - We reviewed the international literature concerning both with comparative studies on efficacy, tollerability and safety of tricyclics and SSRI and with studies of pharmacoeconomics that have focused on the costs of depression and of different antidepressant treatments. Results - Depression involves high costs, especially if indirect costs are considered. Comparative studies indicate a substantial equivalence of efficacy between tricyclics and SSRI, but a better tolerability of the latters. The few studies of pharmacoeconomics that have evaluated different antidepressant drugs indicate that a treatment with SSRI involves lower costs as compared with tricyclics. These results are due to the higher indirect costs (compliance, drop-out for side-effects, work loss, etc.) of tricyclics. Conclusions - A correct economic evaluation of an antidepressant drug treatment should consider both direct and indirect costs. Available studies indicate that SSRI involves lower costs as compared with tricyclics; however in order to confirm these results more studies of pharmacoeconomics are needed with experimental designes (longitudinal studies) taking into account the outcome of patients treated in routine clinical practice.