Concept: Mental Disorder / Mental Health Disorder / Mental Health Illness Classification

Introduction

This concept describes the classification of "mental disorders" / "mental health disorders / "mental health illness" and how this classification has been defined in MCHP research. This includes a list of databases where mental health data resides, the algorithms that have been used to define mental disorders / mental health disorders / mental health illnesses over time, and a list of MCHP research that have investigated mental health, with links to the research results and findings in this research.

The terms mental disorder, mental health disorder, and mental health illness represent the use of varying terminology over time, and all terms combine a variety of specific mental health conditions into one classification for descriptive and reporting purposes. For general purposes of this concept, the term mental disorder will be used.

Data Sources for Mental Disorders

There are several databases available in the MCHP Data Repository that contain data that can assist in defining mental health conditions and diagnoses. The databases include:


• Medical Services data (Physician Claims);
  
• Hospital Abstracts data;
  
• Mental Health Management Information System (MHMIS) data.
  
• Mental Health Information Database (MHID) data; and
  
• Drug Program Information Network (DPIN)

NOTES:

• ICD diagnoses codes are available in the Medical Services, Hospital Abstracts, MHMIS and MHID data.
  
• The DPIN data is used to identify mental health conditions based on the type of medications that are prescribed to treat these conditions.
  
• The majority of MCHP research has used the Medical Services, Hospital Abstracts and DPIN data to identify mental disorders. The MHMIS and MHID data access / approval process is much stricter than most data in the MCHP Data Repository and may explain why this data is less used in MCHP research related to mental health. Please see the Access Requirements section of the Mental Health Management Information System Data Description for more information.

Approaches for Defining Mental Disorders

This section describes the two main approaches that have been used in MCHP research over time for defining mental disorders. In most research, mental disorders are restricted to Manitoba residents aged 10 and older. In recent research, Chartier et al. (2016) looked into mental disorders in children as young as six years old.

1. ICD-9-CM Mental Disorders Classification

The first approach, used in the earliest MCHP research investigating mental health, is based on the ICD-9-CM classification system for mental health disorders (ICD-9-CM codes 290-319). MCHP used this system to identify the following three broad categories:


1. Psychotic disorders (major mental health disorders): ICD-9-CM diagnoses codes 295-299, that includes schizophrenic disorders, paranoid conditions and major depressions. These disorders are typically chronic or persistently recurrent and are associated with serious social and occupational disability. This category of disorder has been termed serious, major, long-term or chronic in other investigations.
   
   
2. Non-psychotic disorders (minor mental health disorders): ICD-9-CM diagnoses codes 300-301, 306-309, and 311 combine mild affective disturbance and neurotic and personality disorders. While some individuals with non-psychotic disorder may have illness of severity and duration equivalent to the disease course of the psychotic disorders, the typical disease course in this class of disorder is shorter, milder and without profound disability impacts.
   
   
3. Other mental health disorders: ICD-9-CM diagnoses codes 290-294, 302-305, 310, and 312-319 comprise a heterogeneous group of conditions, including pediatric behavioural disorders, organic states and mental disorders attributable to addiction and mental retardation.

This algorithm is available in the SAS code and formats section below - see the Mental Illness Classification - SAS Formats file.

2. Specific Diagnosis for Mental Health Disorders / Conditions

The second approach defines specific mental health conditions using ICD codes and prescription medications. These individual conditions can then be combined to describe mental disorders.

The reasoning for this approach is described in the Patterns of Regional Mental Illness Disorder Diagnoses and Service Use in Manitoba: A Population-Based Study deliverable by Martens et al. (2004), In this research, the Need To Know (NTK) Team and the Working Group discussed the categories of mental illness ("psychotic", "non-psychotic" and "other") and decided they would not be used in this research. They felt that more detailed categories would be more reflective of the way in which the mental health population is currently viewed. They felt the terms used in previous research reflected the institutional era, where persons were often categorized psychotic/non-psychotic as an indicator of those who were institutionalized versus not institutionalized. Current mental health professionals regard mental illnesses as having continuums of severity, which can change over time, so the service systems must be flexible to accommodate this change.

More specific terms, such as "depression", "personality disorder", "anxiety states", "substance abuse" and "schizophrenia" were considered more useful in reflecting the types of mental illness disorders currently discussed by planners and providers. The specific conditions / disorders used in individual MCHP research are identified below. Most of the individual conditions were measured and described as "treatment" or "diagnostic" prevalence. This refers to the percentage of the population satisfying the diagnostic coding criteria for a specific mental disorder. We refer to the terms as "treatment prevalence" or "diagnostic prevalence", rather than just "prevalence", since it depends on a person seeing a physician, using a mental health service, or being hospitalized with a mental illness - in other words, receiving a diagnostic coding for a mental illness from a health care service provider. These individual conditions can be used in combination to describe an overall, or cumulative classification called "mental disorders".

MCHP Research Findings

The following sections identifies and describes a number of MCHP research projects that have investigated mental illness / mental disorders over time. These descriptions include how mental illness / disorders are defined in the research.

1. Tataryn et al. (1994)

In The Utilization of Medical Services for Mental Health Disorders Manitoba: 1991-1992 deliverable by Tataryn et al. (1994), they classified mental health disorders into the three broad categories described above: psychotic disorders, non-psychotic disorders, and other mental health disorders, using ICD-9-CM codes. The research investigated the prevalence of mental health disorders among persons aged 18 and older for a one-year period, from April 1, 1991 to March 31, 1992.

People may have multiple mental health diagnoses which may be categorized into more than one group. In this research, people were assigned hierarchically to a single category as follows:


• If an individual had one or more diagnosis in the psychotic disorder category, they were classified as psychotic.
  
• If an individual had one or more diagnosis in the non-psychotic disorder category, and no diagnosis in the psychotic disorder category, then they were classified as non-psychotic.
  
• If an individual had one or more diagnosis only in the other disorder category, then they were classified as other.

Diagnostic information contained in the hospital abstracts, medical services/physician claims and MHMIS (Mental Health Management Information System) data were used for this hierarchical classification of individuals.

Definitions

The following definitions were used in this research:


• "Ever-User" of Mental Health Services - In this study, any person receiving treatment for a mental health reason between April 1, 1991 and March 31, 1992 was defined as an "ever-user" of mental health services. Treatment includes ambulatory and inpatient physician contacts, inpatient and outpatient hospital services, and inpatient services provided at Provincial Mental Health Institutions (PMHI): Brandon, Selkirk Mental Health Centre and Winkler Eden Mental Health Centre). Treatment for mental health reason was defined as any service with a diagnosis in the range 290-319.
  
  It is important to note that since the completion of the mental health deliverable, the Mental Health Management Information System (MHMIS) has not maintained the diagnosis fields consistently. This information source may no longer be a valid source of information regarding the definition of "ever-users". For more information read Mental Health Notes from Cameron Mustard.
  
  
• Acute and Long-term Inpatients in PMHI - Inpatient hospital stays in the PMHIs were counted if any of the diagnostic codes were in the range 290-319 and if a patient was resident for one or more days in a facility during the observation period. Long-term patients in PMHIs were distinguished from acute treatment patients by a number of criteria involving admission status, discharge status and length of stay.
  
  Any inpatient stay at a provincial mental health institution was classified as long-term if any of the following criteria were met:
  
  
  • Patients in PMHIs during FY 91/92, who remain inpatients up to the summer of 1993 (the end of reporting time for the MHMIS dataset provided to MCHP).
    
  • Patients who died in a PMHI and who had a cumulative inpatient stay of greater than 365 days of which all or part occurred in FY 91/92.
    
  • Patients who were discharged to a personal care home and who had a cumulative inpatient stay of greater than 365 days of which all or part occurred in FY91/92.
    
  • Patients who were admitted to a PMHI involuntarily and who had a cumulative inpatient stay of greater than 365 days of which all or part occurred in FY 91/92.
    
  • All other inpatient hospital stays at PMHIs were considered to be acute.
  
  SAS Code for MHMIS Coding
  
  
  • Definition of Legal Status (leglstat=Legal Status from open/close form);

    lglgt0=0;
    if leglstat>'00' then lglgt0=1; /* Involuntary Status */

  • Definition of case closure due to death (close_tp=Close type from open/close form);

    dead=0;
    if close_tp='04' then dead=1; /* Death during inpatient stay */

  • Definition of transfer to personal care home (pmref_ty=primary referral to code from open/close form);

    trans=0;
    if pmref_ty in ('63,65) then trans=1; /* Transfer */

  • Definition of case remaining open (close_dt=close date from open/close form);

    open=0;
    if close_dt='00000000' then open=1; /* Case remains open */

    Note: Detailed definitions of variables from the MHMIS can be found in the MHMIS data dictionary of the Metadata Repository (internal access only).
  
  
• Acute and Long-term Inpatients in the General Hospital Sector
  
  
  • In the general hospital sector all hospital admissions where the principal (or most responsible diagnosis) diagnosis was in the range ICD-9-CM 290-319 were tabulated. Acute admissions were differentiated from long-term admissions on the basis of two things:
    
    • All admissions to Deer Lodge Centre and Municipal Hospital (now called Riverview) were classified as long-term admissions.
      
    • All admissions to acute care hospitals where the primary service code was in the range of "0900"-"0999" or "7300"-"7399" were classified as long-term admissions.
      
    • All other hospital admissions were classified as acute.
  
  
• Psychiatric/Non-psychiatric Service in the General Hospital Sector - acute care stays in the general hospital sector were further classified as admissions to a psychiatric service or a non-psychiatric service. Eight facilities operated psychiatric services during this period: Brandon, Grace, Misericordia, St. Boniface, Victoria, Seven Oaks, Health Sciences Centre and Thompson Hospitals.
  
  Admissions to psychiatric services were distinguished from admissions to non-psychiatric services on the basis of service codes on the hospital abstract. In particular service codes in the range of "6400"-"6599" were defined as psychiatric services. All other services were defined as non-psychiatric.
  
  
• Physician Visits - physician visits are drawn from Ambulatory Visits - Physician claims. Visits with a diagnosis code in the range 290 to 319 were classified as psychiatric services.

2. Mustard et al. (2000)

In the deliverable, A Description of the Use of Insured Health Care Services by Income Assistance Recipients in the Province of Manitoba: A Pilot Study. Recipients of Income Assistance for Mental Health Disability deliverable by Mustard et al. (2000), they compared a group of individuals receiving income assistance for reasons of mental health disability with two other groups; one group was matched on sex, age (within one year) and urban or rural residence. and the second matched on treatment history for a mental health disorder, in addition to sex, age and urban or rural residence. Appendix Table B: Classification of Mental Health Disorders identifies the range of ICD-9-CM codes used to classify specific mental health disorders as psychotic, non-psychotic and other mental health disorders.

The research investigated the use of insured health care services, hospital services and physician services. The results of this research can be found in chapter 3. Results of the on-line deliverable.

3. Martens et al. (2004)

In the Patterns of Regional Mental Illness Disorder Diagnoses and Service Use in Manitoba: A Population-Based Study deliverable by Martens et al. (2004), they investigated mental illness using data from the Hospital Abstracts, Mental Health Management Information System (MHMIS), and Medical Services (Physician Claims) data from 1997/98 to 2001/02, along with some earlier years for validation purposes -- for more information see Appendix 6: Validity Issues Surrounding Mental Illness Diagnoses in the on-line deliverable.

The following lists the specific mental health conditions that were investigated. Links are provided to more detailed information in the MCHP Concept Dictionary, including the methods (e.g.: ICD codes, age restrictions) for defining the condition, and results from individual research, including the methods used in Martens et al. (2004):


• Anxiety disorder - see the Anxiety/Anxiety States glossary term;
  
• Attention-Deficit Hyperactivity Disorder (ADHD) - see the Attention-Deficit Hyperactivity Disorder (ADHD) concept;
  
• Dementia - see the Dementia - Measuring Prevalence concept;
  
• Depression - see the Depression - Defining in Administrative Data concept;
  
• Personality disorder - see the Personality Disorders - Measuring Prevalence concept;
  
• Schizophrenia - see the Schizophrenia - Measuring Prevalence concept;
  
• Substance Abuse - see the Substance Use Disorders / Substance Abuse - Measuring Prevalence concept; and
  
• Suicide and Suicidal - see the Suicide and Attempted Suicide (Intentional Self Inflicted Injury) concept.
  
  NOTE: Fetal Alcohol Syndrome (FAS) was also investigated in this research but not used. FAS was defined as the presence of ICD-9-CM code 760.71 (fetal alcohol syndrome) in the Hospital Abstracts or the Mental Health Management Information System (MHMIS) data. However, these administrative data sources significantly under-count the number of cases when compared to information from the Clinic for Alcohol and Drug Affected Children at Health Sciences Centre, and therefore, FAS analyses was not conducted.

Cumulative and Other Mental Health Illnesses

This research also reported using categories of mental health illness, including:


• Cumulative Mental Health Illnesses: cumulative treatment prevalence was defined as the proportion of the cohort population who received treatment for any of the following five mental illnesses: depression, anxiety states, substance abuse, personality disorders, and schizophrenia.
  
• Other Disorders: "Other Disorders" was defined as the presence of one or more ICD-9-CM code for any psychiatric condition, except those that are described as "cumulative mental health illnesses": depression, anxiety states, substance abuse, personality disorder, and schizophrenia.
  
• Any Disorders: "Any Disorders" was defined as the presence of one or more ICD-9-CM code for any psychiatric condition, in either Hospital Abstracts, Mental Health Management Information System (MHMIS) or Medical Services (Physician Claims) data.

4. Cumulative Mental Illness / Mental Health Disorders

Several subsequent research projects investigated specific mental health disorders and "cumulative mental illness / mental health disorder". This classification was created to provide an overall indicator of the prevalence of mental illness, accounting for the co-occurrence of mental illnesses from the following five conditions: depression, anxiety disorders, substance abuse, personality disorders, or schizophrenia. In one research project, by Ruth et al. (2015), a range of ICD codes were used to identify "mental health related conditions". In these studies, the MHMIS data was not used.


1. In the Manitoba RHA indicators Atlas 2009 deliverable by Fransoo et al. (2009), they compared cumulative mental illness for two different 5-year time periods: 1996/97-2000/01 and 2001/02-20005/06. Prevalence rates were reported by RHA, RHA Districts, and Winnipeg Neighbourhood Clusters. For more information, see section 5.1 Cumulative Mental Illness in the on-line deliverable.
   
   
2. In the Health Inequities in Manitoba: Is the Socioeconomic Gap in Health Widening or Narrowing Over Time? deliverable by Martens et. al, (2010), they compared cumulative mental illness for five, 5-year time periods, covering 1984/85 to 2008/09. The definitions for cumulative mental illness did not include prescription information from the Drug Program Information Network (DPIN) data. The reason for this was to maintain consistency in the definition across time, because the earliest analysis time frame (1984) pre-dated the availability of the DPIN data (1995). Prevalence rates and Lorenz Curves are reported by income quintile. For more information, see Chapter 7: Mental Health in the on-line deliverable.
   
   
3. In the Health and Healthcare Utilization of Francophones in Manitoba deliverable by Chartier et al. (2012), they compare the prevalence of cumulative mental health disorders between a Francophone cohort and a matched cohort, and report the rate ratios between these groups. For more information see section 6.1 Cumulative Mental Health Disorders in the on-line deliverable.
   
   
4. In the Long-Term Outcomes Of Manitoba's Insight Mentoring Program: A Comparative Statistical Analysis deliverable by Ruth et al. (2015), they defined mental health related conditions as any diagnosis code from Chapter 5 (Mental Disorders) in the ICD-9-CM code book or from Chapter 5 (Mental and Behavioural Disorders) in the ICD-10-CA code book, found in either physician visits and/or hospitalization data. An additional mental health condition derived from the Families First Screening form, peripartum social isolation, was also investigated. For more information, please read Chapter 7: Conclusions and Recommendations in the on-line deliverable.
   
   
5. In the Care of Manitobans Living with Chronic Kidney Disease deliverable by Chartier et al. (2015) they investigated specific mental disorders in children and adults as a comorbidity to chronic kidney disease (CKD) and end stage kidney disease (ESKD). A classification of "any mental disorder", a combination of all the specific mental disorders, was also investigated. The specific conditions considered as mental health disorders in adults (18 years and older) in this research included: mood and anxiety disorders, substance abuse, schizophrenia, and personality disorders. For more information, see the section titled:
   
   • Mental Health for rates and relative risks of mental disorders among people with end stage kidney disease.
     
   • Mental Health for rates and relative risks of mental disorders among people with chronic kidney disease.
   
   
6. In the Mental Illness Among Adult Manitobans deliverable by Chartier et al. (2018) they investigated mental illness in adults using the following definition: a diagnosis of mood and anxiety disorders, substance use disorders, psychotic disorders (including schizophrenia) or personality disorders. For more information, see the section titled: Any Mental Illness in the deliverable.

5. Mental Disorders / Mental Health Disorders in Children / Youth

In more recent deliverables, MCHP has investigated mental disorders / mental health disorders in children and youth. In this research, a different set of "cumulative" mental health disorders are investigated compared to the previous research. This is described below:


1. In The Educational Outcomes of Children in Care in Manitoba deliverable by Brownell et al. (2015), they defined mental disorders as one of the following conditions: attention-deficit hyperactivity disorder (ADHD), conduct disorder, mood and anxiety disorders, schizophrenia and substance use. For more information about the definitions (e.g.: ICD codes, age restriction) of these disorders, click on the links provided. The research investigated three different cohorts: ever in care, ever received CFS services, and never in care/never received CFS services. For more information on the results pertaining to mental disorders found in this research, see the section titled Mental Disorders in the on-line deliverable.
   
   
2. In the Care of Manitobans Living with Chronic Kidney Disease deliverable by Chartier et al. (2015) they investigated specific mental disorders in children and adults as a comorbidity to chronic kidney disease (CKD) and end stage kidney disease (ESKD). A classification of "any mental disorder", a combination of all the specific mental disorders, was also investigated. The specific conditions considered as mental health disorders in children (age 0-17 years old) in this research included: attention-deficit hyperactive disorder (ADHD), mood and anxiety disorders, developmental disabilities, schizophrenia, and substance abuse. For more information, see the section titled: Mental Health for rates and relative risks of mental disorders among children with chronic kidney disease and end stage kidney disease.
   
   
3. In The Mental Health of Manitoba's Children deliverable by Chartier et al. (2016) they investigated the diagnostic prevalence of mental disorders in Manitoba's children as well as the health and social services use, justice system involvement, and educational outcomes of children with mental disorders, and examined the relationship between physical health and mental health, as well as the association between parental and child mental health status. They defined "any mental disorder" for children aged 6-19, as any diagnosis for the following mental disorder: attention-deficit hyperactive disorder (ADHD), conduct disorders, substance use disorders, mood and anxiety disorders, and psychotic disorders. In children aged 6-12, only three of these conditions were considered for "any mental disorder". Substance use disorder and psychotic disorder were excluded.
   
   For more information, see the section titled Any Mental Disorder in the on-line deliverable. This section reports key findings, and graphical illustrations of differences over time (from 2005/06-2008/09 to 2009/10-2012/13) by Health Regions and Winnipeg Community Areas, by age groups and sex, and by income quintile.
   
   
4. In The Overlap Between the Child Welfare and Youth Criminal Justice Systems: Documenting "Cross-Over Kids" by Brownell et al. (2020) they investigated mental disorders in youth (ages 12-17). The specific conditions considered as mental disorders in this research included: attention-deficit hyperactive disorder (ADHD), conduct disorder, mood and anxiety disorders, psychotic disorders, and substance use disorder. For more information, see the Mental Disorders and Intellectual or Developmental Disabilities section of this report.