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Information systems in psychiatry

For a century and a half there has been statutory collection of mortality and hospital morbidity statistics. The procedure has remained essentially the same, with the main innovation being the separation of first and subsequent admissions. Although hospital records often have contained detailed information on patients, traditionally only a few descriptive items have been reported by the hospitals to government. The data have been published annually in the familiar form of simple cross-tabulations between demographic features, diagnoses, individual hospitals and periods of stay. As Shepherd (1957) and Richman (1966) have noted, mental hospital statistics have been put to good use in descriptive studies in the United States, Scandinavia and Britain. The figures were used by Goldhamer & Marshall (1953), for example, to show that in Massachusetts the admission rate for the psychoses had been constant for the century starting in 1850; and their systematic reporting enabled Malzberg in New York (1952) and 0degaard in Norway (1961) to undertake their monumental studies in mental hospitals. The slow passage of the insane through the mental hospitals and their causes of death were well monitored by these statutory information systems. So, while the mental hospital populations reached their peak in the mid-twentieth century, earlier statistics already had revealed altering discharge rates and lengths of stay (Shepherd, 1957). Despite its demonstrated value, this massive information system has been roundly criticized. It pertains to events or groups of patients and not to individuals, the reliability of demographic and diagnostic data has been uncertain, and the psychiatric information has not been linked with that from medical and social agencies. In reviewing the many government reports published in Britain, Maynard & Tingle (1974) emphasized the limited amount of information published compared with that collected and noted that even elementary statistical manipulations have not been undertaken. Little (1975) reminded us that even serial censuses only afford a picture of usage of resources and not needs of people. It would seem then that, while the psychiatric morbidity statistics have been employed occasionally in the planning and evaluation of mental hospital statistics (Tooth & Brooke, 1961; Lancet editorial, 1971), they have not been used routinely in their present form when decisions regarding the allocation of resources are made. It is known that there is lack of uniform methods of data collection (Brooke, 1963; Kramer, 1969), low reliability of assigned diagnosis (Babigian et al. 1965; Kendell, 1974) and varying descriptions of first admissions, psychiatric facilities and age groupings (Brooke, 1963; Kramer, 1969). Kramer (1976) has concluded that, since morbidity rates are influenced by so many nosocomial factors and not assessed systematically, the handicap for planners and evaluators can only be lifted by having special research units organize systematic and comparative morbidity statistics. Such units would necessarily obtain more accurate hospital morbidity rates, case fatality rates and population denominators. To an extent, this has been undertaken by case registers, defined by Richman (1970) as 'systems whereby records from a specified set of psychiatric facilities are collected for individual persons from a defined population and accumulated over time'. They record all psychiatric cases in discrete geographical areas but require a stable population and data in a standard format, preferably collected by trained interviewers (Hailey, 1971; Hall et al. 1973). Following their success in cancer and tuberculosis, registers were recommended by the WHO Expert Committee on health statistics, although diagnosis and comprehensiveness of data were noted to be weak points in psychiatry. As a result, registers have been established in several countries. They aim to collect reliable information with protected confidentiality and provide sampling frames for incidence, prevalence and longitudinal