dalla rivista World Psychiatry del giugno 09
Functional impairment can have different meanings
MYRNA M. WEISSMAN
Department of Psychiatry, College of Physicians and Surgeons, Columbia University; Division of Epide-miology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
Bedirhan Ustun and thè World Health Organization (WHO) group have done thè most sophisticated research on thè assessment of disability as an integrai part of psychiatric classification. As they note, thè concept of disability adjusted life years (DALYs) changed thè view of psychiatric disorders. Mental illness as compared to serious medicai illnesses appeared high on thè list of DALYs because mental disorders begin early in life and do not result in early mortality, so that thè number of years lived with thè disorder is often quite long, resulting in many more DALYs. The high rate of DALYs for psychiatric disorders, demonstrated across thè world, has had a profound effect on thinking about psychiatric illness and has made thè assessment of functional impairment and disability important in any psychiatric classification System.
In this paper, thè WHO group proposes to unify thè measurement and collection of data on disability between thè DSM and thè WHO's International Classification of Functioning, Disability and Health (ICF). I agree with thè importance of unifying these systems and also with developing operational criteria for mak-ing thè assessments.
The authors state that thè concept of functioning is a neutral one, encompassing all decrements to body functions, activities, involvement in life situationswhich are known at thè body level as impairment, at thè personal level as activity limitation and at society level as participation restrictions. The authors point out that there is similarity between ICD and DSM in thè operationalization of diagnosis. The notable exception is that ICD does not require clinical significance to make a diagnosis but requires thè ICF operational criteria of disability as a separate domain.
The DSM-IV Global Assessment of Functioning (GAP), thè ICF checklist and thè WHO Disability Assessment Scheduled (DAS) all include measures of social functioning which are comparable, such as interpersonal interactions, getting along with people, and occupational or school functioning. These areas can easily be translated across domains and also have relevance cross-culturally.
I would question using items like learning and applying knowledge or communication, which are absent from thè GAP, as part of functioning and disability criteria. These items are related to education, income and IQ. Their inclusion in an assessment of disability may confound functioning with education.
Bedirhan Ùstùn suggests that thè ICF domains need to be operationalized and I would strongly agree, as similar domains may still have different interpreta-tions. Several years ago, we were asked to compare three functioning scales in a primary care study (1). All three of these scales (thè Medical Outcome Study, 36-item Short Form Health Survey, SF-36; thè Social Adjustment Self-Report, SAS-SR; and thè Social Adaptation SelfEvaluation Scale, SDSS, measure work functioning. All scales, when applied to patients in a primary care study, were able to differentiate between psychiatrically ill and well people. However, thè correlations between thè scales were modest even in thè areas covering similar domains. A comparison of thè questions included in thè scales showed how thè approaches to work assessment differed. The SAS-SR assesses thè actual number of days lost, thè effective performance and interpersonal relationships on thè job, whereas thè SDSS emphasizes interest and motivation, and thè SF-36 asks about problems with work. While each of these scales covered thè area of assessment of work, their approaches to work functioning were quite different. We reccommended that
investigatore selecting a functional status assessment instrument carefully review thè content of each scale and, if a broad range assessment is very critical, use more than one scale.
In conclusion, I would agree fully with Bedirhan Ùstùn and thè WHO's recommendation that functional impairment be assessed separately from symptoms. It will be useful to have this assessment similar across thè different diagnostic systems. Considerable attention needs to be paid to thè comparability of thè questions in each of thè domains.
Factors that influence functional impairment and outcome of mental illness
FRANK NJENGA
Upper Hill Medicai Center, Nairobi, Kenya
Ùstùn and Kennedy's article raises a number of issues that frequently occupy thè mind of thè practicing psychiatrist.
There are many instances in which mild disorders cause severe disability, while at other times severe disorders do not seem to cause much functional disability. A common occurrence in clinical practice is when a patient with what seems like schizophrenia that is not severe gradually deteriorates in his ability to manage his affairs without any discernible worsening of thè clinical symptoms. In this case, there is a marked disconnect between thè severity of thè disorder and that of thè attendant social and functional disability.
In seeking to get a greater understanding of these two concepts, other complicating but relevant and important factors quickly come into play. Cultural and social environment give an example of how a mild condition with severe disabling consequences in one environment can have minimal disabling consequences in another environment. In thè typical rural, nomadic lifestyles of thè semiarid pastoral communities of Eastern Africa, powerful systems of social support exist, that enable persons with moderate to severe disease to exist within thè community without much ev-ident disability (1). In contrast, thè severity of mental disorder would have devastating consequences and manifest as severe disability in urban and periurban slums in big African cities, where social support systems do not exist, and where urban poverty, crime, and poor infrastructure conspire to ensure that survival is only for thè fittest. African urban life would thus make disability more evident in such cases.
Treatment or lack of it has a similar though not thè sanie effect. Severe but treated mental illness can end up with minimal disability, while mild but un-treated disorder could have thè oppositeeffect. Access to available medicai care is a complex subject and is not simply a function of thè availability of service. Stigma, education and distance from thè service are but a few of thè many factors that come into play (2).
In many cultures, mental illness remains thè subject of great stigma and shame (3). In places where patients with thè mildest of disorders are hidden from sight to avoid thè shame of such conditions, thè disability would seem to be out of proportion with thè severity.
Another factor that often makes mild disorders have features of great disability is lack of care or treatment. Persons without social or family support drift to thè fringes of society without necessarily being severely ill, but become disabled in thè sense of being unable to cope with thè demands of family living.
Attention-deficit/hyperactivity disorder (ADHD) is a common mental disorder (4) that in clinical practice displays thè great contrast between severity of disorders and thè magnitude of disability. Procrastination is a common symptom of ADHD. In some cases it assumes great prominence as it interferes with role performance, including, in young people, educational achievement, pro-fessional qualifications, and involvement in relationships that could lead to maritai unions. Such individuai appear superfi-cially well, but over a period of adult life become severely disabled and incapable of independent life, and in need of care and protection.
In thè process of conceptualizing disability in relation to clinical severity, there are instances where severe mental disorder does not (as in thè above example) lead to significant functional impairment. Morbid jealousy (5) is a ready example of a disorder of great severity but in some cases with unimpaired social and occupational function. The suf-ferer is completely disabled in one sphere (marriage), but functions completely well in others such as work. Clinicians describe instances where a man will set upvery elaborate spying networks to catch a cheating wife, will spend much money and energy to catch her in thè delusional belief of infidelity. Many such men, at least in thè early stages of thè disorder, do not display any form of functional impairment, in spite of suffering a highly significant clinical disorder which, if un-treated, could lead to loss or thè murder of a spouse.
Anorexia nervosa remains a very con-troversial subject in Africa (6). The available evidence seems to suggest that it is a rare disorder among indigenous African populations. Genetic, environmental, and cultural explanations have been put forward to explain this observation (7). The situation in Europe and America is thè opposite, with great disability visiting millions of young women, who in thè view of thè Africans "simply refuse to eat food". Viewed from this perspective, one begins to understand how a disabling condition in one continent can have little or no significance in another.
The efforts to define disability operationally and separate it from thè disease process faces other challenges. In thè 21st century, millions of people work and live in countries other than where they were born. Some migrate for politicai, economie or security reasons. The case of thè Somali people is a good example of a people without a home in thè ordinary sense, and who are now geographically spread across thè world, in East Africa, Europe and America.
The demands placed on such immigrants by a new language, technology, weather and thè simple fact of being "alien" generate further mental health challenges in those with mild or even severe mental illness. Being a new immigrant in itself places an additional burden on an individual, making what would be mild disability at home become severe disability in thè adopted home. Compilations of data on disability among immigrant communities must remain cognizant of this reality.
Clinicians come across severely functionally disabled men and women who in their countries of origin functioned as professionals in law, medicine, engineering and other fields. In these cases, severe disability is as much a function of thè disease process as it is a function of all those factors that created thè refugee status.
Any future systems of classifìcation must attempt to address all these issues, and state clearly thè limitations posed by thè many variables at play in any clinical or research situation.
References
1. Kebede D, Alem A, Shibire T et al. Symp-tomatic and functional outcome of bipolar disorder in Butajira, Ethiopia. J Affect Dis-ord 2006;90:239-49.
orso castano : il disturbo mentale pio' esere comparato solo con poche altre malatie croniche per la sua durata. e questo da' rilievo alle difficolta' cognitive ed operative che il disturbo implica. Le scale di valutazione che riguardano l'area lavorativa e le disabilita' sociali difficlmente possono essere usate come se i deficit in queste aree fossero dei sintomi (oltretuto queste scale possono essere usate da non medici) . Pertanto l'area della disabilita' , pur potendo essere complementare a quella della sintomatologia clinica , e' diversa da essa e richiede una diversa valutazione. E' come se si dovesse giungere alla composizione di un quadro unitario attraverso due diverse diagnosi. Del resto , ad esempio non sempre i disturbi schizofrenici provocano severe ripercussioni nell'area delle disabilita' sociale o lavorativa. L'ambiente, come ricordato gioca un fattore determinante sia come risorse che puo' offrire sia come collocazione geografica. L'articolo porta l'esempio della schizofrenia negli ambienti urbani africani. Fa poi altri esempi come l'ADHD e la situazione mentale degli immigrati (ricordo qui' il bel libro di Risso-Castelnuovo, Einaudi, "A mezza parete") fino alla "dissonanza cognitiva" (meglio sarebbe pèrecisare un tipo particolare di dissonanza cognitiva) che , molto acutamente, l'articolo considera come componente strutturale dell'immigrato in un paese straniero. In sintesi articoli da leggere a fondo..........
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