CASE CONTROL – EPIDEMOLOGY DESIGN

SEMESTER VII
FOUNDATIONS ON CLINICAL PSYCHOLOGY
ASSIGNMENT

Submitted by:
A.Sneha and Shynu KS
19IBS001K & 19IBS022H
Integrated B.Sc - M.Sc Clinical Psychology (4th Year)

Submitted to:
Ms Betzy Varghese
Department of Psychology
Jyoti Nivas College, Bangalore
 CASE-CONTROL STUDY

Definition:
A type of study in which a group of individuals diagnosed with a disease or other
condition is compared to a group of individuals without the disease diagnosis,
specifically with regard to the proportion of people in each group who were exposed
to a certain risk factor. Also called case-control design (APA)

The observational epidemiologic study of persons with the disease (or other outcome)
of interest and a suitable control (comparison/ reference) group of persons, without
the disease. (Dictionary of Epidemiology: 3rd ed: John M Last. 2000)

These studies move from effect to cause (e.g., health outcome, condition, disease) (exposure).
Case-control studies look to see if there is a disproportionally distribution of exposure
between cases and controls, which may indicate that the exposure is a risk factor for the
health outcome under research. Case-control studies are commonly used to investigate rare
health outcomes or diseases.

In contrast to cohort or cross-sectional studies, subjects in case-control studies are chosen

because they have the desired health outcome (cases). The exposure status is not used in the
selection process. Controls, people who are not affected by the health outcome under
research, are drawn at random from the population from which the cases arose. The case-
control study uses sampling to accomplish the same goals as a cohort study (comparison of
exposed and unexposed subjects).

After identifying cases and controls, the investigator determines the proportion of cases and
controls that have been exposed to the exposure of interest. As a result, the case-control study
common factors do not represent the total number of exposed and non-exposed people in the
source population.

Types of cases used in case control studies

Incident case: a person who is newly diagnosed as a case.
Prevalent case: a person who has a health outcome of interest that was diagnosed in the past.
Risk ratio: the likelihood of a particular health outcome occurrence among persons exposed
to a given risk factor divided by the corresponding likelihood among unexposed persons.
Exposure odds ratio: the odds of a particular exposure among persons with a specific health
outcome divided by the corresponding odds of exposure among persons without the health
outcome of interest. Yields a valid estimate of the incidence rate ratio or risk ratio derived
from a cohort study, depending on control sampling.

Prevalent cases are all people who had the health outcome or disease during the observation
period. These studies produce a prevalence odds ratio, which is influenced by the incidence
rate as well as survival or migration out of the prevalence pool of cases and thus does not
estimate the rate ratio. Incident cases, or people who develop the health outcome or disease
for the first time during the observation period, can also be used in case control studies.
Remember that both incidence and duration have an impact on prevalence. Researchers who
study disease causes typically prefer incident cases because they are more interested in
factors that contribute to disease development rather than factors that affect disease duration.

Selecting controls

Selection of controls is usually the most difficult part of conducting a case-control study. We
will discuss 3 possible ways to select controls:
1. Base or case-base sampling

2. Cumulative density or survivor sampling

3. Incidence density or risk set sampling

Base sampling or case-base sampling: This sampling method uses controls drawn from the
source population so that each individual has an equal chance of being included as a control.
This sampling method can only be used with a previously defined cohort. The odds ratio
provides a valid estimate of the risk ratio in these case-control studies without assuming that
the disease is uncommon in the source population.
Cumulative density sampling or survivor sampling: When controls are drawn from those who
remained free of the health outcome at the end of the follow-up period, the sampling is
referred to as cumulative density sampling or survivor sampling. When using this type of
sampling, controls can never have the outcome (become cases). In these case-control studies,
the odds ratio only estimates the rate ratio if the health outcome is uncommon, that is, if the
percentage of those with the health outcome in each exposure group is less than 10%.
(Requires the rare disease assumption).

Incidence density sampling or risk set sampling: We call this type of sampling incidence
density sampling or risk set sampling when cases are incident cases and controls are selected
from the at-risk sample group at the same time as cases occur (controls must be eligible to
become a case if the overall health develops in the control later during the period of
observation). The control series estimates the proportion of total person-time in the source
population for exposed and unexposed cohorts. The odds ratio estimates the rate ratio of
cohort studies in these case-control studies, without assuming that the disease is uncommon
in the source population.

Source populations for case-control studies

Source populations can be narrowed down to a specific population of interest, such as

postmenopausal women at risk of breast cancer. This restriction makes controlling for
unnecessary comorbid conditions in the population easier. Controls should reflect the limited
source population from which cases emerge, rather than all non-cases in the total population.
The study's cases do not have to include all of the instances in the total population.

Sources of cases
 Cases diagnosed in a hospital or clinic

 Cases entered into a disease registry, e.g. cancer, birth defects, deaths

 Cases identified through mass screening, e.g. hypertensives, diabetics

 Cases identified through a prior cohort study, e.g. lung cancers in an occupational
asbestos cohort
Sources of controls

1. Population controls are non-cases drawn from the source population of cases. This is
the preferred method for selecting controls. Finding and recruiting population-based
controls can be accomplished through random sampling from census block groups or
a registry such as the Department of Motor Vehicles (of adults who can drive).

2. Controls from the neighbourhood or among friends are appropriate if these people
would be counted as cases if they developed the health desired result. It is not
appropriate to use neighbours or friends as controls if they have the same level of
exposure.

3. Hospital controls - There are some issues with hospital controls in that they may not
be from the same sample group as the cases. Hospital controls may not be
representative of the vulnerability prevalence in the source population of cases; for
example, there may be a high incidence of smokers in hospitals. Hospital controls
may also have diseases caused by the exposure of interest, for example, smoking is
linked to the disease of interest (cancer) as well as heart and pulmonary diseases from
which the controls may suffer.

4. Controls with another disease - However, if the study is on lung cancer, for example,
cancers known or believed to be related to the study exposure of interest must be
excluded. These controls, like hospital controls, have some of the same issues.

Advantages of case-control studies

 Case-control studies, which require a much smaller study sample than cohort studies,
are the most efficient design for rare diseases.
 Investigators can avoid the practical hurdles associated with following a large sample
over time. Thus, case-control studies enable a more in-depth evaluation of case and
control exposures.
 Case-control studies using incidence density sampling or risk set sampling produce a
valid estimate of the rate ratio derived from a cohort study if incident cases are
studied and controls are drawn from the source population's risk set.
  When done correctly (i.e., with appropriate sampling), case-control studies provide
information similar to that obtained from a cohort study, but at a much lower cost and
time.

Disadvantages of case-control studies

 Because the value of these measures is not defined, case-control studies do not
provide an estimate of rate or risk.

 Recall bias may exist in case-control studies if exposure is measured through

interviews and recall of exposure differs between cases and controls.

 If historical records are available to assess exposure, investigators may be able to

avoid this problem.

 Choosing an appropriate source population is also difficult and may contribute to

selection bias.

 Case-control studies are inefficient for studying rare exposures (less than 10% of
controls are exposed) because it takes a large number of cases and controls to detect
the effects of rare exposures.

CASE STUDY 1: Cognitive Change in Schizophrenia and Other Psychoses in the Decade
Following the First Episode

Participants were from a population-based case control study of first-episode psychosis

patients who were followed prospectively for up to ten years after admission. A
neuropsychological battery was administered to patients with schizophrenia (N=65) or other
psychoses (N=41) as well as healthy comparison subjects (N=65) at the index presentation
and at follow-up.

The schizophrenia group showed declines in IQ, verbal knowledge, and memory measures,
but not in processing speed or executive functions. Processing speed and executive function
impairments were present at the start of the episode and remained stable after that. Memory
decline was not limited to schizophrenia patients; it was also observed in patients with other
psychoses. Healthy people with low IQ showed no signs of decline, implying that the decline
is unique to psychosis.

After the onset of schizophrenia and other psychoses, patients experience cognitive decline,
but the magnitude of decline varies across cognitive functions.
Unique pathways resulting from the illness and/or psychosocial factors may underpin
impairments in various cognitive functions.

CASE STUDY 2:

A hospital-based unmatched case control study was carried out in four Tigray zonal hospitals.
There were 954 study participants (318 cases and 636 controls). The cases and controls were
chosen using systematic sampling. Throughout the study, ethical approval was obtained.

389 (40.8%) of the 954 interviewed mothers had experienced intimate partner violence
during their index pregnancy period. Intimate partner violence was present in more than two-
thirds (68.6%) of the cases.
According to a multivariable logistic regression analysis, women who experienced intimate
partner violence during their pregnancy were three times more likely to have a low birth
weight and a preterm birth. Women who had been subjected to physical violence during their
pregnancy were found to be five times more likely to have low birth weight and preterm
birth.

It was discovered that when pregnant women were exposed to more than one type of intimate
partner violence and physical violence during pregnancy, the risk of preterm birth and low
birth weight increased.
References:
 SERIES, E. N. Authors: Lorraine K. Alexander, DrPH Brettania Lopes, MPH Kristen Ricchetti-
Masterson, MSPH Karin B. Yeatts, PhD, MS.
 Mann, C. J. (2003). Observational research methods. Research design II: cohort, cross
sectional, and case-control studies. Emergency medicine journal, 20(1), 54-60.
 Zanelli, J., Mollon, J., Sandin, S., Morgan, C., Dazzan, P., Pilecka, I., ... & Reichenberg, A.
(2019). Cognitive change in schizophrenia and other psychoses in the decade following the
first episode. American Journal of Psychiatry, 176(10), 811-819.
 Berhanie, E., Gebregziabher, D., Berihu, H., Gerezgiher, A., & Kidane, G. (2019). Intimate
partner violence during pregnancy and adverse birth outcomes: a case-control
study. Reproductive health, 16(1), 1-9.