Case Vignette in a Community-Based Study

To the Editor: We read with interest the article by Shelly F. Greenfield, M.D., M.P.H., et al. (1) regarding the effectiveness of the voluntary screening program for depression. It strikes us that part of the screening was conducted through telephone interview and that it was effective in bringing certain depressed individuals for treatment. Unfortunately, such a program cannot be conducted in a developing country such as Malaysia because the majority of the houses in the rural areas do not have telephones and because there are problems in communication, especially in the remote areas. In such situations, we need to modify the methodology in order to reach the target population. We want to share our experience in conducting a community-based study and treating those who refused psychiatric treatment.

We have been conducting a psychiatric morbidity study to assess the prevalence of major psychiatric disorders in one of the districts in the state of Kelantan, on the east coast of peninsular Malaysia. “Probable cases” were detected through key informants after field workers presented five vignettes portraying mental retardation, acute psychosis, chronic schizophrenia, mania, and depression. At the end of the interview, the informants were asked whether they had observed any person in the village matching the description in the vignettes.

If the informant’s answer was convincing, he or she was asked to identify the person. The field workers then contacted each of these individuals (“probable cases”) to determine the details of any illness and make appointments with the project psychiatrist for further psychiatric assessment. This part of the study was equivalent with the first stage of the usual two-stage case identification, when the screening instrument to measure symptoms reflecting general psychological distress is administered. Usual instruments, such as the General Health Questionnaire, are not suitable in our situation because a substantial proportion of the target population is illiterate.

In our study, the probable cases were assessed by a psychiatrist using the Structured Clinical Interview for DSM-III-R (SCID) (2) to determine the presence of specific psychiatric disorders. The subjects were diagnosed according to DSM-III-R. The preliminary results revealed that 92 subjects with psychiatric diagnoses had been identified through 34 informants. The majority of the subjects had the diagnosis of schizophrenia. Most of the subjects with psychiatric diagnoses had never received psychiatric treatment, but a small percentage of them had sought traditional treatment. The negative attitude toward psychiatric treatment was reflected by the finding that about one-third of the subjects determined to be probable cases had to be visited in their homes because they refused to come to a nearby clinic, in spite of the fact that we sent a few reminders. Most of the subjects with psychiatric disorders accepted our treatment after a home visit; however, some of them refused to be treated because they did not have confidence in modern Western medicine.