Beyond the Survey: Epidemiology For the 21st Century

Myrna Weissman, PhD

Professor of Epidemiology and Psychiatry, Columbia University

This interview was conducted by Peter Cook on June 29, 2006.

After graduate school at Yale University, Dr. Myrna Weissman was part of the first large-scale epidemiological community surveys of psychiatric disorders in the US. “At that time,” she says, “there were epidemiologic surveys being done on cancer, heart disease, and other physiological ailments which I had learned about in school. Psychiatry, which was my interest, was not at the table. The surveys in psychiatry focused on stress or overall wellness. None in the U.S. examined the epidemiology of specific psychiatric diseases.” Dr. Weissman and many other colleagues in collaboration examined the rates of psychiatric disorders in 18,000 Americans. Later she compared the U.S. results to results in 9 other countries. “Our major finding was that the majority of psychiatric disorders began in childhood, not middle-age. These findings, I think, contributed to a shift in psychiatric research and treatment.” Since completing large scale surveys she has moved on to case-control and longitudinal studies of patient populations and families. Having seen the birth of contemporary American psychiatric epidemiology, it seems only fitting that Dr. Weissman is now revolutionizing the field, and is among those responsible for bringing epidemiology into the 21st century.

Transitioning From Survey Research

“I still do epidemiology,” Dr. Weissman says, “but not much survey research.” Instead, she is focusing on integrating epidemiology with brain imaging and genetics. The survey research she does do is clinical, focusing on patients and families instead of the general community. Currently, Dr. Weissman is working on a series of studies with her colleagues at Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute examining the prevalence of psychiatric disorders in the primary care population. “We’re interested in this population because, while there’ve been a number of studies on psychiatric disorder in the primary care setting, they’ve mostly been HMO-based, and have sampled a largely white, middle-class, working population. The population around the Columbia hospital is predominantly composed of poor minorities, many recent immigrants.” Dr. Weissman has finished 2 survey studies on this population, and is now working on a third. Overall, she and her colleagues have surveyed over 2,000 primary care patients, and they’ve found that rates of psychiatric disorders are significantly higher in the outpatient primary care population than has been reported in studies focusing on white, middle-class patient populations. Dr. Weissman believes that minority under-representation is a problem in contemporary epidemiology. African Americans are especially wary of participating in research largely due to the history of abuse in research. Tuskegee is well-known in the African-American community.

Another of Dr. Weissman’s studies based out of Columbia, focusing on the children and grandchildren of depressed parents and grandparents, has been in the works for 20 years. They recently reported their findings: the increased risk of depression and anxiety disorders in the offspring of depressed vs not depressed parents continues as they move into adulthood and is transmitted to the third generation, the grandchildren. Over 60% of the grandchildren with 2 generations affected with depression already had a psychiatric problem. Their average age was 12 years old.

“In these studies we’ve been very interested in implementing modern technologies available in genetics and neuroimaging,” Dr. Weissman says. “When we started them, back in the 70s, genetic approaches were underdeveloped, and brain imaging applications were basically non-existent. In our 3-generation study we’ve already performed 190 MRIs and gathered 140 blood samples for DNA.” The results aren’t in yet, but Dr. Weissman hopes to be done within 2 years, and further hopes that the information will offer up valuable new insights into the genetic and pathophysiologic mechanisms of depression in this high risk sample.

Impacting Practice

“I’ve always been interested in how our research findings can make a positive impact on patient care,” Dr. Weissman says. “Whenever I undertake a study, I ask: ‘what’s this going to do for patient relief besides give us another publication?’” “Epidemiological research can offer evidence-based answers to questions about screening, and early detection. For example, 2 clear messages from our 3-generation study are that children of depressed mothers are more likely to be depressed—and vice versa—and that depression in the young has serious, lasting consequences. These two facts lead to some very evident guidelines for screening and treatment of depression in children and adults.” One of Dr. Weissman’s recent studies indicated that successful treatment of depression in the parent has a positive effect on the depressive symptoms of the child.

More clinics are instituting mandatory screening for depression and some other psychiatric disorders in the primary care setting. If the patient is a parent of a young child questions about the child should be part of the package. However, according to Dr. Weissman, lack of time and money are still huge roadblocks. She believes the will to implement increased psychiatric screening is there, but it’s not always feasible for doctors in a primary care setting. “If you have ten minutes to diagnose a patient with a host of physical ailments, you don’t have much time to screen for depression,” she points out.

Advances in understanding the risk and mechanisms of the major psychiatric disorders require scientific collaboration among investigators with different skills, including genetic epidemiology. These are long term studies. Our group is involved in a multi-centered study including Columbia University, Howard University, Johns Hopkins University, University of Iowa, Stanford University, and University of Illinois. This study follows the epidemiologic findings on the high familial nature of early onset recurrent major depression, includes some of the known environmental factors which increase risk and is a comprehensive genetic study which will have information on clinical characteristics, environmental risk and DNA on 2,000 persons. The data collected without identifying information—to preserve confidentiality—will be made available to scientific investigators working on depression throughout the world and will become increasingly valuable as new technologies are being developed. “A new feature of the study,” Dr. Weissman says, “is our efforts in collaboration with Howard University and Harlem Hospital to recruit African Americans who have been largely underrepresented in these studies.

We are very interested in recruiting persons for our genetic study of depression. Since interviewing and blood drawing can be done in the home we recruit from all over the country.”

In summary, epidemiology received considerable prominence in the 1980s as the first surveys were done to estimate the prevalence of psychiatric disorders in the community using modern diagnostic criteria. These surveys continue and are important in monitoring changes in rates of psychiatric disorders and in determining the cross-cultural variations. Now, epidemiology with its emphasis on sampling, ascertainment, research design and statistics, assessment of diagnosis, environmental risk, and demographics has become a partner in a host of studies involving a range of new technologies. “These are very exciting times. Epidemiologic training is really training in basic scientific methodology and approaches to scientific questions. It provides wide latitude to ask a variety of questions from risk to treatment efficacy and wide opportunities to collaborate with scientists who are highly specialized in other approaches.”

Disclosure: Dr. Weissman receives grant support from Eli Lilly, GlaxoSmithKline, NARSAD, and NIMH.