10.1192/bjp.150.6.815Access the most recent version at doi: 1987 150: 815-823 The British Journal of Psychiatry

  JR Copeland, ME Dewey, N Wood, R Searle, IA Davidson and C McWilliam  

Prevalence in Liverpool using the GMS-AGECAT packageRange of mental illness among the elderly in the community.  

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British Journal of Psychiatry (1987), 150, 815—823

Range of Mental Illness Among the Elderly in the CommunityPrevalence in Liverpool Using the GMS-AGECAT Package

J. R. M. COPELAND,M. E. DEWEY,N. WOOD, A. SEARLE,I. A. DAVIDSONand C. McWILLIAM

A sampleof 1070 elderly personsaged over 65 living in the Liverpoolcommunity wasinterviewed usingthe community versionof the Geriatric Mental State (GMS) and thefindingsprocessedto providea computeriseddiagnosisby AGECAT. Levelsof organicdisorder,probablydementia, reached5.2%, intermediatebetween those of LondonandNew York derived from previous studies. Levels for depressive illness overall were belowthose of other studiesat 11.3% while levelsfor neuroticdisorderwere much the sameat 2.4%. The rise in the prevalenceof dementia with age was further confirmed. TheGMS AGECAT Packageprovidesa method for standardisingboth the collectionof dataand the diagnosticprocessfor comparativeepidemiologicalstudiesand other research.

Reviews by Kay & Bergmann (1980) and Henderson& Kay (1984)of the prevalenceof mental illness incommunity studies of the elderly show that figuresfor mild and severe mental illness vary considerablybetween such studies. The use of diverse techniqueshas made it difficult to interpret the cause of thesedifferences. The importance of standardised methodsfor collecting data has been stressed and suchinstruments are now in use. However, to improveaccuracy further it is necessary to standardise twomore stages, the decision on diagnosis, and thedefinition of case levels of illness, particularly ofminor illness, in a reliable manner.

In the US/UK Cross-National (Diagnostic) Studyof the elderly in the cities of New York and London,Gurland et al (1983) used the CARE interviewdeveloped from the Geriatric Mental State (GMS)(Copeland et al, 1976; Gurland et al, 1976). Theyalso developed a method for identifying levels of‘¿�pervasivedementia' and ‘¿�pervasivedepression'. TheDiagnostic and Statistical Manual, (DSM-III) of theAmerican Psychiatric Association (1980) also setsforward criteria for the diagnosis of both dementiaand depression, and the Research Diagnostic Criteria(Spitzer et al, 1978) for depression. Althoughrepresenting advances in technique, these methodsstill allow too much individual interpretation of thecriteria, (Jorm & Henderson, 1985; Copeland &Gurland, 1985).We consider it necessary for psychiatric epidemiology, to standardise the diagnostic andcase-selection processes by using as reliable a methodas possible if the comparative studies of populationsare to be interpretable. Copeland et al (1987a),recently re-examined the New York/London community study of the elderly and applied the computerised

diagnostic system AGECAT to the data. In two largestudies (Copeland et a!, 1986; Copeland et al, 1987bAGECAT diagnosis has been shown to approximatereasonably closely to the diagnosis of psychiatriststrained in the British tradition. A computer methodof diagnosis has the disadvantage that it must awaitinput of the data to the computer, but it has theadvantage of consistency, can take into considerationa wider range of unusual combinations of symptoms,can reliably categorise subcase as well as case levels,and can provide symptom profiles and scale scores.

The study reported here was undertaken as partof a pilot longitudinal study aimed at examining theearly detection of dementia in the community elderly.The sample therefore excludes those elderly residentin institutions.

Method

Interviewing techniques: GMS and AGECAT

The development of the GMS has been describedin detailelsewhere (Copeland ci a!, 1976; Gurland ci a!, 1976).

GMSA, the shortenedversion of the GMS for use in thecommunity, was developed specially for this study byselecting those GMS items derived from a series ofdiscriminant function analyses applied to data from theLondon communitysample(Copelandeta! 1987a),aimedat distinguishing between depression and dementia;depression, dementia and other psychiatric diagnoses; allpsychiatricdiagnosesand non-cases.It coversthe importantsymptom areas for the psychotic and neurotic disorderslikely to be encountered in the community and AGECATcan be applied to it. This interview is also a syndrome casefmding instrument. A not dissimilar interview (GMS6) wasderivedindependentlyby Hendersonand his colleaguesinCanberraby an intuitiveselectionof items,but unfortunately

815

816 COPELAND ET AL

AGECAT has only limited application to this version forthe identification of subcases.

AGECAT (Copeland et al, 1986; Dewey & Copeland,1986;Copeland et a!, 1987b)consists ofa computer programderived from a theoretical model which was subsequentlytested against psychiatric diagnosis. It groups the items ofthe OMS and related interviews into 157 symptomcomponents. These components are gathered under eightdiagnostic ‘¿�clusters'and allocated to groups according totheir importancefor establishingthe certaintyof diagnosisfor that diagnostic cluster. For example, in the organiccluster the groups concern ‘¿�mildmemory disturbance';‘¿�moderate memory disturbance and time disorientation';and ‘¿�place/persondisorientation and organic thoughtdisorder'. While those for depression represent ‘¿�depressivemood'; ‘¿�non-specificsymptoms of depression'; ‘¿�symptomscharacteristic of neurotic, reactive depression or dysthymicmood'; ‘¿�symptomsdenoting severity'; ‘¿�symptomscharacteristic of psychotic, endogenous depression or majoraffective disorder'; and ‘¿�moodcongruent hallucinations anddelusions'. Each subject is awarded a level from 0—5formost diagnostic clusters according to the certainty ‘¿�ofdiagnosis' on that cluster. All levelson each cluster are thencompared across clusters, one with another, according toa hierarchy of illness starting with organic and proceedingto schizophrenic, manic, depressive (psychosis andneurosis), obsessional, hypochondriacal, phobic andanxiety. The subject emerges with a main diagnosis and asubsidiary or alternative diagnosis if appropriate, the levelson all eight diagnosticclusters, the routes by which theselevels are achieved, a symptom profile, a decision onwhether or not the condition reaches the ‘¿�syndromecase'stage, organic and depressive scale scores and anOrganic/Depression Index (Copeland et al, 1986b, l987a).

A ‘¿�syndromecase' is reached when a psychiatristrecognises that a subject's symptoms have formed arecognisable diagnostic pattern. In practice, this usuallyimplies the need for professional intervention. Bereavementreaching syndrome case level on the depressive cluster isan example of an exception. Syndrome cases may thereforebe further defused, as requiring or not requiring suchintervention. A subject may reach case level on severalsyndromes. AGECAT will select one of these as the overalldiagnosis.We then refer to this as a ‘¿�diagnosticsyndromecase of -----‘.Most studies will require additional casecriteria tailored to the aims of the study. We have calledcasessoselected,‘¿�criterioncases'.Inthisstudywe reportlevels of illness at the ‘¿�syndromecase' and ‘¿�diagnosticsyndrome case' stage.

The agreement between AGECAT and psychiatrists'diagnoses was compared in an initial study (Copeland eta!, l986a) and in a replication study (Copeland eta!, l987b).For 396community-basedsubjects in the initial study thex value for overall agreement was 0.74, for cases ofdepression0.80, for organic cases0.88 and for non-cases0.74. For the replicationstudy,diagnosticconcordancewasreached on 89% of 647 community subjects, giving a valuefor Cohen's x overallof 0.71, for depression0.73, and fororganic disorder 0.77. The last was complicated by theintroduction of a third category of ‘¿�borderlineorganic' case.Where the decision was case/non-case, x reached 0.89 for

organic disorders. These studies and others show thatpsychiatrists trained in different centres appear to agree withAGECAT diagnoses for both institutionally based andcommunity based subjects.

The sample

The 360 General Practitioners forming the Liverpool FamilyPractitioners' Committee were randomly sampled toprovide 58 names. These GPs were approached by a letterexplaining the study and requesting permission to interviewtheir patients. Three refused permission at this stage, leaving55 who were randomly allocated to 11 subsamples of fivepractitioners each. Each subsample formed a randomsample in its own right. Failure to complete one subsamplewould not have invalidated the random nature of the totalsample, and separate subsamples were available forindividual studies.

The potential pool of subjects was 12909. In order toprovide approximately 1000 subjects, 2425 or 19% of theavailable pool were selected from cards held by the FamilyPractitioner Committee. In the event, only nine of thesesubsamples were required.

Each subject was sent an individually signed letterdescribing the project, accompanied by a letter ofintroduction from the OP. The explanatory letter stressedthe randomselectionof the subjects,the natureof the healthsurvey, that it was not ‘¿�anofficial survey' and that therewas no obligation to take part. An address and telephonenumber for contact were also given. Written or verbalrefusals were accepted without question, otherwise subjectswere visited up to four times if necessary, whether or notthey replied to the letter. To a small number of subjectswho objected to being approached in this way a personalletter of explanation was sent.

Interviewers

Six interviewers participated in the project, three full-timeand three part-time. Two of the full-time interviewerspossessedfirst degreesin psychologyand the third wasanex-wardsister(SRN)withgeriatricexperience.Two of thepart-time interviewers had degrees in psychology and onean HNC in medical subjects.

Training on the OMSwasundertaken usingvideotapedand liveinterviewsin the usual manner. A short pre-pilotstudy was undertaken in a geriatric day hospital to test theconfidence of the interviewers when confronted withpatients with mental and physical illness. Inter-raterreliability was assessed using 19 videotaped interviews ofcommunity residents. Each of the six non-medicalinterviewers recorded two or three interviews while the threemedically qualified raters who participated in the followup study (see below) each recorded two. All raterssubsequently viewed and scored each other's interviws. Theresults are to be reported (Forshaw et a!, in prep.).Satisfactory agreement between trained non-medical andmedical raters for the Present State Examination has beendemonstrated (Cooper eta!, 1977) and there is little reasonto suppose that this can not be achieved for older age

RaterOrganicmean

scores.d.Meanages.d.12.63.373.37.122.43.175.16.932.43.772.65.942.42.973.56.853.13.474.56.163.14.673.26.2

Selected from GPs'list2425(19°!.)Discoveredalreadydead114Discoveredalready movedaway270Subsamplesdrawn but notused,not

traced or GPrefused555Sampleeligible forstudy1486Refused

interview416(28°!.)Sampleinterviewed1070

RANGE OF MENTAL ILLNESS AMONG THE ELDERLY 817

TABLE ILiverpoo!: Comparison of mean organic scores and

subject's mean age for each rater

that of both the London and New York samples. The lowproportion of male subjects aged between 80 and 84 isprobably a result of the First World War. Both subjectswho refused interview and those who were not traced havea similar age distribution to the full sample.

TABLE HLiverpoo!: Random sample of subjects aged 65 and overliving in the community of Liverpoo! city: response rate

Tota! estimatedsubjectsavailab!e aged 65 and over: 12 909

Organic score F=0.44 (NS); Age F= 1.62 (NS).

subjects. Meanwhile, Table I shows a comparison ofsubjects' organic mean scores and age for each rater. Theorganic score was made up of those items which bestdiscriminated between organic disorders and other mentalillness, and between organic disorders and non-cases, usinga seriesof lineardiscriminantfunctionanalyses.The ratingof organic symptoms was particularly important for thestudy as a whole.The variation betweenraters is not greatfor the overall organic mean score nor for the mean ageof subjects seen. Standard deviations are similar anddifferences are not statistically significant.

Initial test battery

All subjects, at the initial interviewlasting 50-90 minutes,received: a first blood pressure reading; a healthquestionnaire;a social informationquestionnaire;a numberof psychological tests includingthe SET Test, the NationalAdult Reading Test, and the Mill Hill Vocabulary Test; thesecond blood pressure reading; the GMSA; and the thirdblood pressure reading. The Stockton Behaviour RatingScale was abandoned early in the study as unsuitable fora community population of comparatively well subjects.

A subsample of dementing subjects had a physicalexamination, computed tomographic scan, biochemicalinvestigations and an interviewby a psychiatristusing theGMSA.

Results

Table!! shows the overall response rate. As expected, theGPs listswereinaccurate.Althoughplacesof residencewererepeatedly visited where necessary and attempts made togatheradditionalinformation, a proportionof subjectswasnot accounted for. One GP refused accessto his patientsafter the interviewing started. In all, 1070 or 72°/sof theeligible sample were interviewed. Although the procedurein Liverpool was similar to that used in our London studiesthe response rate was 9°/slower, only a little above thatfound in New York. We discuss this further below.

Table III shows the distribution of the sample by agedivided into half decades. The proportions of male andfemale subjects are not significantly different from eitherthose found in the 1981census for Liverpool city or in thestudy in London. The mean age of 74 years is similar to

Responserate 72¾

Table IV showssomeof the other demographicfeaturesof the sample. They differ little from the census statisticswheretheseare available,and apart from ‘¿�race',are similarto those found in the previous London and New Yorkstudies.

Prevalence

Table V shows the male and female distribution of themajor psychiatric syndromes. AGECAT diagnosticconfidence levelsof 3 or above are used to defme ‘¿�syndromecases'. It was our experience based on the London and NewYork studiesthat acuteorganicstatesare rarelydiagnosedin community samples. Therefore, subjects with AGECATdiagnostic organic disorders quoted here are likely to besuffering from dementia (overall 5.2°!.).

The total proportion of cases of all diagnoses is 19.3°/s.The proportionsof subjectswithno AGECATlevelon anyof the syndrome clusters is 47°/sfor males and 37°/sforfemales. Thus over one-third of the population had noimportant psychiatric symptoms.

Organic disorders

Table VI shows the distribution of AGECAT diagnosticsyndromecasesand subcasesof organicdisordersaccordingto levels of confidence of diagnosis. AGECAT organiclevels which are associated with diagnostic cases of otherconditions are not included. There are some 14 ‘¿�routes'bywhich subjects may be allocated to organic confidencelevels. In general, to achieve level 01 there must be a scoreof at least 2 on symptomsof mild memory disturbance,such as failing to remember the interviewer's name,miscalculatingthelengthof timeatthepresentaddress,the rater's opinion that the memory defect is a problemfor the subject, etc, whilefor level02 a higherproportionof such symptoms is required or others of moderate memorydisturbance, inability to calculate age, failing to recall the

Subject1981census Not trac

Males Females Full sample Liverpool etcAge n % n % n %edrefused

interview%65—69

151 44 192 56 343 32 34333070—74115 37 194 63 309 29 29272675—7986 38 142 62 228 21 20192280—8432 28 84 72 116 11 11121385—8920 36 36 64 56 517 17 6

90+ 6 33 12 67 18 2) ) 31 j95441038 660 62 1070 100 100100100Mean

age 74TABLE

IVLiverpool:Social class, marital state andraceSoda!

dassAdaptedfromRegistrarGenera!'s

classjficationnn%I

15 1.4 Whitecollar30128.1II136 12.7 Bluecollar38435.9III521 48.7Unskilled/service22420.9IV143 13.4 Houseperson(personal

service)928.6V123 11.5Missing696.5Houseperson

orinadequatelydescribed 635.9Missing

69 6.51981

censusLiverpoolMarital

state n % Racen%Currently

married 474 44.3 44.0 Caucasian106499.4Widowed434 40.6 Mongolian20.2Divorced/separated

32 3.0 55.7 56.0 Negroid20.2Nevermarried 125 11.7 Unknown20.2Unknown

5 0.5

818 COPELAND ET AL

TABLEIIILiverpool: Distribution of the sample by age and sex (males n = 410, females n = 660)

interviewer's name on the second occasion or misidentifyingobjects. Case level 03 is reached when a substantial numberof such symptomsis recorded often accompaniedby timedisorientation. Higher levels, 04 and 05 (the communityversion of the OMS did not provide for these levels at thattime) require the presence of severe disorientation in placeand person as well as organic thought disorder.

A higher proportion of female subjects is evident at thecase level but not at the subcase level (P<0.00l). If, asanticipated, subcase levels01 and 02 mainly represent minoracute confusional states there is no reason to suppose that

these would be more common in female patients. Theywould also be expected to include early cases of dementiabut these would be comparatively rare. Subjects achievingany kindof AGECATorganiclevelrepresent9.3% of maleand 10.6% of female subjects. The difference is notstatistically significant.

Figure 1 shows the distribution of AGECAT ‘¿�diagnosticsyndrome cases' (03 and above) of organic disorder by ageand sex. There is a linear relationship between age and thelogit of the proportion of demented subjects (P<O.OOl).The fall after age 90 is a less certain finding because of the

Manles ¼Femnales¼Totalnsample¼AGECAT

diagnosticsyndrome case

OrganicDepressionSchizophrenia]

paranoidNeurosesOther11

31

1312.7

7.6

0.20.70.245

90

2316.8

13.6

3.50.256

121

126

25.2

11.3

0.12.4

0.2Total

cases4711.515924.120619.3Total

sample4101006601001070100

AGECATorganicconfidencelevelsSubcaseCase01

0203 Totalsamplen¼n¼n%nMales163.9

112.7112.7410Females111.6142.1456.8660Combined272.525 2.3565.21070

RANGE OF MENTAL ILLNESS AMONG THE ELDERLY 819

25.0TABLEV

Liverpool:ComparisonbysexusingAGECATdiagnosticsyndromecases(malesn= 410,femalesn= 660)

25

0@ 20

0

00.E

15

& 10U)0

U)0U)0

16.7

11.9

8.5

TABLEVILiverpool: Distribution of AGECA T diagnostic organicsyndromes(caseand subcase)by levelsof confidenceofdiagnosis(malesn=38, 9.3%, femalesn= 70, 10.6%)

few subjects in this age group. The proportion aged over80 with organic disorder is only 12.1°!.,rather below theoften quoted figure of 20°/s(this sample does not includethe comparatively small proportion of institutionalisedsubjects).

Depressive illness

Table VII shows the distribution of AGECAT diagnosticsyndrome cases and subcases of depressive disorders bylevels of diagnostic confidence. The table excludes thoselevels of depression associated with diagnostic cases of otherconditions. There are over 60 ‘¿�routes'for achieving levelsof confidenceon the depressivecluster.As a rough guide,levelDl isachievedby subjectswithminormoodsymptomsand somesymptomsof non-specificdepression,suchas lossof concentration, interest, lack of enjoyment, lack ofenergy, etc., D2 requires a higher proportion of suchsymptoms.Case levelsof depressiveneurosis(DN3)musthave characteristic symptoms in addition, such as,depressionworse in the evening,difficulty getting off tosleep, depersonalisation, feelings of loneliness, etc. in the

0 Female@ Male

. 65-69 @T0-74•75-79•§0-84•85-89•90+,

80+ 12.1%Age

FIG. 1 Distribution of AGECAT diagnostic syndrome cases oforganicdisorder(mainlydementia)by ageand sex. (Fullsample:males n=410, females n=660.)

absence of more psychotic symptoms. Level DN4 isachieved if more severe symptoms (group D) are alsoprominent, such as, the future appearing bleak, wishingto be dead, feeling worthless, having conceived a suicidalplan or attempted to carry it out. Case levels of depressivepsychosis(DP)requiresymptomssuchas, depressivemoodworsein the morning, beingunable to cry, slownessin themorning, early morning wakening, retardation on examination, muddledthinkingand a combinationof appetiteandweight loss. Level 4 of depressive psychosis depends on theprominenceof groupD symptomsand levelSon thepresenceof mood congruent delusionsand/or hallucinations.

There is a consistent tendency for there to be a higherproportion of female subjects at each depressive level ofdiagnostic confidence (P<0.05). In all, 17.3°/sof males and24.9°/sof females are nominated as either diagnosticsyndrome depression subcases or cases. For the full samplewith the sexes combined, 10.7°!.of subjects achievediagnostic syndromesubcase leveland 11.3°/scase level,making a total proportion of 22.0°/s.The overall prevalenceof diagnostic syndrome cases of depressive psychosis is3.0%.

I I

nSubcaseDl¼ nD2 ¼AGECAT

depressive

Depressive neurosisDN3 DN4

n ¼ n ¼confidence

levelsCase

DepressivepsychosisDP3 DP4 DPS

n ¼ n ¼ n ¼Totalsample

nMales215.1194.621

5.1 3 0.7@—¿�@-------@

5.9°/s2

0.5 5 1.2 0 0@- -@

1.7°/s410Females416.2335.054

8.2 11 1.7

9.9°/s16

2.4 8 1.2 1 0.2

3.6°/s660Combined625.8524.975

7.0 1.4 1.3@—¿�@---

8.3°/s18

1.7 13 1.2 1 0.1

@-@

2.9°/s1070

820 COPELAND ET AL

TABLE VIILiverpool: Distribution ofAGECATdiagnostic depressivesyndromes(caseandsubcase)by levelsof confidenceof diagnosis

(malesn= 71, 17.3%, femalesn= 164, 24.9%)

fl Female@ Male

4.7

•¿�65-69 •¿�70-74•¿�75-79•¿�80-84 •¿�85+Age

FIG. 2 Distribution of AGECAT diagnostic syndrome cases ofdepressive psychosis (DP) by age and sex. (Full sample: malesn=410, females n=660.)

Figure 2 shows the distribution of AGECAT ‘¿�diagnosticsyndrome cases' of depressive psychosis by age and sex.Subcase levels are excluded from this figure. Again, thereappears to be a preponderance of female subjects at all halfdecades except one.

Figure3 shows the distribution of ‘¿�diagnosticsyndromecases' of depressive neurosis by age and sex. Again, a higherproportionof femalepatientsis evidentat each half decade.

Neurotic disorders

Table VIII shows the distribution of AGECAT diagnosticsyndromecases and subcasesof neuroticdisordersby levelsof confidence of diagnosis and by sex. The table excludesthose neurotic levels associated with diagnostic cases ofotherconditions. For the threeconditionsobsessive, phobicand anxiety neurosis there is a tendency for rather higherproportions of subjects to be found at level 2 than at thecase levels.

Whether or not a subject achieves syndrome case levelson the hypochondriasiscluster largelydepends on whether

2

.@0.E

I

Fio.3 DistributionofAGECAT diagnosticsyndromecasesofdepressive neurosis (DN) by age and sex. (Full sample: malesn=410, Females n=660.)

he or she shows undue preoccupation with physicalsymptoms for which there is no apparent cause. Forsubjects on the obsessional cluster to reach syndrome caselevels the symptoms must interfere with daily living.Subjects at level 0B2 have genuine obsessional symptomsin so far as they have rituals or compulsive thoughtswhich they attempt to resist. For subjects to achievesyndromecase levelon the phobic cluster there must beevidence of active avoidance or in more extreme cases thesubjectmust be housebound.To achievesyndrome caselevels on the anxiety cluster subjects must complain ofor show evidence of somatic symptoms or symptoms oftension.

6.0

Age

0

6

O@4

U@ 2

SubcaseCaseTotalsampleHypochondriasisnHC1

¼HC2nHC3¼HC4nMales

Females1 10.24 0.152 30.49 0.46410660ObsessiveOBIn0B2

¼n0B3¼0B4OBSnMales

Females10 92.44 1.3610.15410660PhobicPHinPH2

¼nPH3¼PH4nMales

Females15 373.66 5.6181.20410660AnxietynAN1

¼nAN2 ¼nAN3 ¼nAN4¼ANSnMales

Females12 92.93 1.3664 10215.6115.45101.521 10.24 0.15410 660

RANGE OF MENTAL ILLNESS AMONG THE ELDERLY 821

TABLE VIIILiverpool:DistributionofAGECATdiagnosticneuroticsyndromes(subcaseandcase)bylevelsof confidenceof diagnosis

(malesn= 105,25.6%, femalesn= 181, 27.4%)

AGECA T neuroticconfidencelevels

level represents substantial neurotic symptoms (althoughthey may not interfere with daily living), and becausecase/non-case distinctions are somewhat ‘¿�arbitrarily'chosenfor neurotic conditions, the overall prevalence rises to24.6°/s(males 8.6°/s,females l6°/s,NS). If all diagnosticsyndrome cases and subcases of neurotic disorders areincluded, the overall prevalence is 26.7°/s.Only levels ofphobic symptoms are significantly different between thesexeswithfemaleshavingrathermoresymptomsthan males(P<0.05).

Figure 4 shows the distribution of AGECAT diagnosticsyndrome cases of neurosis by age and sex. The higherproportion of female cases is evident, (P<0.003). Theapparent decline with age is not significant.

Response rate

5.6

65-69 •¿�70-74 75-7980-84 ‘¿�85+Age

Discussion

Although the same procedures were used in bothLiverpool and London, the response rate was lowerin Liverpool. It is similar to the response rate in NewYork and a little below that achieved by Kay et a!(1985) when both their younger and older samplesof the elderly in Hobart are combined. The reasonswhy subjects refuse to take part in a study are variedbut it is our impression that a substantial proportionof refusals are caused by misinterpretations of the

II1@2

w(9

Fia. 4 Distributionof AGECATdiagnosticsyndromecasesofneurotic disordersby age and sex. (Full sample:malesn =410,females n=660.)

TableVIII showsthat althoughneuroticsyndrome‘¿�case'levels as defined here are rare in these age groups, highproportionsof neuroticsymptoms, particularlyanxiety,areoften present. On the evidence of previous studies,confidencelevels4 and Sfor anxietyare uncommon,unlessassociated with diagnostic cases of depression, dementiaor schizophrenia. The overall prevalence of diagnosticsyndrome cases of neurosis is 2.4°/s(males 0.3°/s,females2.1°!.).However, if those subjects with diagnostic subcaselevel2 are includedwith the caseson the grounds that this

EliFemaleMale

Mn

822 COPELAND ET AL

study's aims and a failure to appreciate its importancein terms either of the usefulness of its results or inits financial outlay. Even when attempts are madeby letter to explain the importance of interviewingboth the well and the ill, this may still not be trulyappreciated by the subject. We have found in subsequent studies that a substantial improvement inresponse rate occurs, if a preliminary visitor calls atthe house to explain in person the nature of theproject. Such a procedure increases the overallexpense of the project but can also save interviewer'stime if the preliminary visitor arranges preciseappointments.

As there were no significant differences in agedistribution between those who were interviewed andthose who refused interview, we do not expect tohave lost a higher proportion of cases than non-cases,although this always remains a possibility in suchstudies.

Prevalence

Organic disorders

The level of 5.2% for diagnostic syndrome casesof organic disorder (probably mostly dementia)compares with 4.3% for London and 8.3°lofor NewYork. All prevalence figures for the New York andLondon studies quoted here are those given byCopeland eta! (1987a) derived from the applicationof AGECAT to the New York and London CAREdata. Mental state item differences between theCARE Schedule and the OMSA are small and, inany case, diluted by the pooling of items to form thesymptom components. It is unlikely, therefore, thatdifferences in prevalence can be ascribed to differences in the technique used.

The age distribution in the Liverpool sample issimilar to that in the London sample. The prevalenceof organic disorders in males in Liverpool is similarto that in London, while that in females lies midwaybetween the New York and London figures. Theoverall proportion of organic syndrome subcases liesbetween the London and New York figures. Thecombined proportions of subcases and cases of10.1% and the proportion for cases of 5.2% areremarkably similar to the findings of the originalNewcastle studies (Kay eta!, 1964) of approximately10% for both mild and severe organic brainsyndromes and 4.9°lofor severe alone.

Depression

The overall prevalence figure of 11.3% for diagnosticsyndrome cases of depressive disorders is somewhat

below that for either New York 16.2%, or London19.4%. It is accounted for by a lower proportion ofcases (also subcases) of depressive neurosis, while theoverall prevalence for cases of depressive psychosisof 3.0% is slightly above that for either New Yorkor London. The City of Liverpool is noted for itshigh level of social problems, particularly unemployment, crime and drug dependence. However, it hadbeen anticipated in the London/New York studies,that the prevalence of depression would be higherin New York than in London because of theadditional social problems in that city, the presenceof which were amply documented by the study.Nevertheless, the proportions of depression foundin London and New York were similar. It thereforecannot be assumed that the level of depressive illnessor depressive symptoms in a community will bear adirect positive relationship to the level of socialdisturbance. This may be related to the well-knownfinding that certain types of psychiatric morbidityare negatively correlated with social disturbancessuch as war. As for the affective disorders as a whole,if the diagnostic syndrome subcase levels of 10.7%and the case levels of 11.3% are added together toequal 22.0%, this figure is not far short of the 26.2%for mild-to-severe levels of affective disorder givenin the Newcastle studies. The Liverpool diagnosticcase level of 11.3°lois close to the figure of 10.0°!.for moderate/severe affective disorders, found inNewcastle. The Liverpool figure of 3.0% forpsychotic depression is close to the figure of 3.7/sfound by Blazer & Williams (1980) using DSM-IIIcriteria for major affective disorder in a communitysample aged over 65 years.

Neurotic disorders

The overall prevalence for diagnostic syndrome casesof neurosis in Liverpool of 2.4°/smay be comparedwith 1.4°/sin New York and 2.0°/sin London. Thereare no important differences in syndrome case levelsfor any of the individual neurotic disorders betweenthe three cities. If all diagnostic syndrome levels forobsessional disorders are taken together (cases andsubcases) the prevalence is 1.7°/sfor the Liverpoolsample, close to the 0.7°/sfor the New York sample,but much lower than the figures for London of9.8°/s.2.4°/sis also remarkably close to 2.6°/sfor‘¿�other'functional diagnoses found by the Newcastlestudy after the removal of cases of schizophrenia,paranoid illness and affective disorders.

There are few differences between the sexes forthe neurotic disorders and there is no consistentpreponderance of males across the age-span as wasevident in the combined London and New York

RANGE OF MENTAL ILLNESS AMONG THE ELDERLY 823

samples. Neurotic symptoms may fail to reach caselevel because elderly people may have a lifestylewhich allows them to avoid contact with provokingfactors.

The measures

The GMS-AGECAT Package offers a method forundertaking comparative studies of elderly populations. It introduces a degree of standardisation notonly into the collection and recording of symptomsbut also into the selection of diagnosis. A range ofinformation is provided about each subject includingthe identification of case and subcase levels ofdiagnostic confidence.

In the study described here the diagnoses weremade in terms of eight diagnostic clusters. Historicaldata were not available at the time. If more exactdistinctions are to be made between, for example,dementia and acute confusional states; and betweentypes of dementia, other chronic organic conditionsand pre-existing mental subnormality; historical datawill be essential. The History and Aetiology Scheduleis being used in the follow-up studies now beingundertaken. Data from this interview pass into thenext stage of AGECAT which aims to divide theeight diagnostic clusters into subgroups. It providesinformation on the form of onset and developmentof the illness, family history, previous illnesses, headinjury and alcohol and drug abuse.

Acknowledgements

Theauthorswouldliketo acknowledgethehelptheyreceivedwiththe interviewingfromMaryHeary,JosephineSilcock,ColleenHensey, and Jenny Wood and to give their thanks to MichaelKayodi for his work on the computer, to Barbara Ackerley forcalculatingthe proportion of subjectsnot contactedand ArthurPugh for preparingthe diagrams.Theyalsowishto expresstheirgratitudeto the GeneralPractitionersin Liverpoolfor their help.and the community residents who gave up their time to beinterviewed. The study was supported byamajor competitive awardfromthe WelcomeTrust,andtheWorldHealthOrganisasion.

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‘¿�JohnR. M. Copeland, MA, MD, FRCP, FRCPsych,Professor and Head of Department; Michael E. Dewey,BA, ABSsS, Lecturer in Psycho!ogica! Statistics; Neil Wood, MA, PhD, Research Worker', Robina Searle,BA, Research Worker; Ian A. Davidson, MRCPsych, Lecturer in Psychiatry; Christopher McWilliam,MRCPsych, Lecturer in Psychiatry,Department of Psychiatry,Universityof Liverpoo!

‘¿�Correspondence:Universityof Liverpool,P0 Box147,Liverpool