Disablement

The most comprehensive measure is the Disability Assessment Schedule (DAS)(56) that assesses an individual's functioning in daily life. Its short form (53 is suitable for survey use. Self-completion instruments are the Brief Disability Questionnaire ( BDQ)(58) and the SF-36(59) or its briefer version, the SF-12.

Possible causes of mental disorders: the domains

Having specified the psychiatric disorder or class of symptom and having developed methods to measure it, the next task is to measure whatever factors are suspected to contribute to its onset or course. These lie in the traditional three domains: the biological, social, and psychological. But in epidemiology, any variable used to tap these is rarely specific to one domain. Some biological, some social, and some psychological factors are often conflated. For example, gender expresses biological differences but may also carry different social experiences in the past, different social contexts in the present, and different psychological or intrapersonal differences in personality traits and behaviour. Likewise, age-group can also reflect social role, educational opportunities in the past, marital status, and physical health. It is therefore important not to be misled into thinking that a variable is tapping only what one is primarily interested in. Confounding is ever present—and often unexpected.

Sociodemographic variables

When data on a population sample is divided by age, gender, marital status, ethnic background, and socioeconomic or educational level, the average level of psychiatric morbidity may differ significantly. Depressive disorders are consistently more prevalent in women (69 and dementia has a higher prevalence in groups with low education/6 62) Furthermore, there may be important interaction effects between variables in their relation to morbidity. For example, the average age of onset in schizophrenia is different in men and in women (see Ch.aptei,4.3.4).

The social environment

This can be considered in two parts: first is the individual's immediate social environment—what the sociologist Cooley (63) called the primary group—consisting of those around a person with whom there is both interaction and commitment. There is then the wider community with its standard of living, lifestyle, and cultural values. Plausibly, both may have some influence on the incidence of mental disorders and on their course. Instruments to measure the individual's immediate social environment and the support it may afford have been usefully reviewed by Turner.(64) Most instruments are interviews taking about 30 min.(65,66) The hypothesis that social support protects against depression and other common mental disorders has proved hard to investigate. (6Z> This is because social support is probably influenced by some intrapersonal factors rather than being a product solely of the individual's environment. Here is a good example of confounding: a major variable concerning the social environment of individuals turns out to be determined not solely by environmental factors, but partly by their own personality attributes. The evidence suggests that social support, stripped of these confounding factors, is not a powerful factor in aetiology. (68) A separate issue is whether social support influences the outcome of psychiatric disorders once these have developed.

Societal (macrosocial) variables have long been suspected of playing an important role in aetiology. It was such a hypothesis that was investigated in the celebrated Stirling County Study in Canada by Dorothea and Alexander Leighton(6 I9> with their concept of sociocultural disintegration. The current increase in depression and suicide in the young is also attributed to a macrosocial variable. The problem is that satisfactory indicators are elusive.

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