The latest U.S. mental health tracking survey shows mixed results of progress

• A Decade's Worth of Advances in Therapeutics, Awareness Campaigns, and Greater Health Plan Access to Mental Health Care Resulted in a Dramatic Increase in Treatment;
• Nonetheless, a High Proportion of the Population Continue to Have Mental Disorders and Many Remain Untreated;
• Six Percent Have Severe Disorder;
• Quality of Treatment is Often Low;
• Early Interventions Aimed at Children Recommended

BOSTON - The conclusions of the latest U.S. mental health tracking survey show a continued high prevalence of mental disorders, but also show that most cases are mild and only a small proportion are severe, according to leaders of the survey from Harvard Medical School, University of Michigan Institute for Social Research, and the National Institute of Mental Health. The survey, known as the National Comorbidity Survey Replication (NCS-R), is taken every 10 years to assess the mental health of the country.

In a set of four papers published in the June issue of Archives of General Psychiatry, the survey authors reported that a majority of Americans will have a mental health disorder at some time in their life, but that most are mild; that those disorders often go untreated; and that even when treatment does occur, the care provided will likely not meet recommended mental health treatment guidelines for the disease.

"It's been a decade since the first National Comorbidity Survey (NCS) was taken, and many important advances have been made in mental health care in terms of new medications, public attitudes, and financing of treatment," says Ron Kessler, HMS professor of health care policy, who directed both the NCS and NCS-R surveys. "Because of these factors, treatment has increased dramatically. We were hoping to see a decrease in disorder prevalence because of this, but we did not. Quality of treatment was found to be low in many cases. The good news, though, is that many cases were found to be mild."

"This new report demonstrates again that mental disorders are the chronic diseases of the young with high rates in the population," says Dr. Thomas Insel, Director of the National Institute of Mental Health. "While some of these disorders are mild, this survey also finds that 45 percent of those with mood disorders and over 20 percent of those with anxiety disorders are severely affected. Identifying the milder cases that will progress to severe will be an important goal for preventing disabling mental illness."

The survey examined four classes of disorders: anxiety disorders (such as panic and post-traumatic stress disorders), mood disorders (such as depression and bi-polar disorders), impulse-control disorder (such as conduct and attention-deficit/hyperactivity disorder), and substance abuse disorders (such as alcohol and drug abuse).

A FULL LIST OF DISORDER TYPES AND A BREAKDOWN OF RESULTS BELOW.

Lifetime Prevalence and Age-of-onset of Mental Illness

The authors found that most Americans will meet the diagnostic criteria for one or more mental health disorders at some time in their life, with first onset usually in childhood or adolescence.

Anxiety disorders (experienced by 28.8 percent of Americans at some time in their life) were found to be the most prevalent class of disorders, followed by impulse-control (24.8 percent), mood (20.8 percent), and substance use (14.6 percent) disorders. The most prevalent individual lifetime disorders are major depressive disorder (16.6 percent), alcohol abuse (13.2 percent), specific phobia (12.5 percent) and social phobia (12.1 percent).

The ages of onset found in the survey were consistent with those reported in previous surveys, with anxiety disorders having the earliest ages of onset (the majority starting in childhood) and mood disorders the latest (the majority starting by the age range 20-25). The study showed that mental disorders gain the strongest foothold by attacking youth, with risk substantially lower among people who have matured out of the high-risk age range.

Delay in Seeking Treatment

The study found that a large number of people never seek treatment for their disorders. This is especially true for substance and impulse control disorders, where nearly half of all lifetime cases failed to ever obtain treatment.

The authors also found pervasive delays in initial treatment contact among those who eventually obtained treatment, with average delays lasting years or even decades for some disorders. Delays for anxiety disorders ranged from 9 to 23 years, for mood disorders from 6 to 8 years, for impulse-control disorders from 4 to 13 years, and for substance disorders from 5 to 9 years.

Prevalence and Severity of Mental Illness in a Given Year

Like the lifetime prevalence study, the authors found that in a given year in the U.S. DSM-IV disorders are very prevalent. Anxiety disorders (experienced by 18.1 percent of Americans each year) are the most prevalent, followed by mood (9.5 percent), impulse-control (8.9 percent), and substance (3.8 percent) disorders.

This 12-month snapshot also looked at disorder severity. Twenty-two percent of the 12-month cases were classified as serious, 37.3 percent moderate, and 40.4 percent mild. More than 40 percent of 12-month cases had more than one disorder, and the severity of mental illnesses was found to be strongly related to having multiple disorders. Impulse-control disorders, which have been neglected in previous epidemiological studies, were found in one-third of cases and these cases were typically more serious than either anxiety or substance disorders.

Treatment and Quality of Care in the 12-month Snapshot

The survey found that mental health service use remains low, with the majority of cases not receiving any care in the prior year. Only 41 percent of 12-month cases received some treatment in the past 12 months, including 12.3 percent treated by a psychiatrist, 16 percent by a non-psychiatrist mental health specialist (psychologist, social worker), 22.8 percent by a general medical provider (physician, nurse), 8.1 percent by a human services provider (spiritual advisor), and 6.8 percent by a complementary-alternative medical provider.

Those who successfully accessed health care often did not receive treatment consistent with even minimally accepted standards in published treatment guidelines. Only 12.7 percent of the patients seen for mental health problems by general medical providers received minimally adequate care. Also striking was the frequent use of non-medical treatments with uncertain benefit. This is especially worrisome when looking at complementary and alternative medicine, which accounts for 32 percent of all mental health visits.

Barriers to treatment

The study found that disorders that began in childhood, although often more serious than those that started in adulthood, were associated with the longest delays in seeking treatment. The researchers speculated that the reasons for this are that minors may be less likely to receive timely treatment because they need the help of parents or other adults and recognition of symptoms is often low among these adults unless symptoms are extreme. The authors also found that men sometimes have longer delays and lower rates of treatment contact than women, and that longer delays were found among minorities compared to non-Hispanic whites.

Recommendations

"Given the enormous personal and societal burdens of mental disorders, these observations should lead us to direct a greater part of our thinking about mental health interventions to children," says Kessler. " We should focus on early interventions aimed at preventing progression of primary disorders and the onset of multiple disorders."

Kathleen Merikangas, the lead NIMH collaborator in the study, notes, "Outreach efforts are needed to increase access to and initiation of treatments, such as expanded availability of evaluations or voluntary screening programs to detects early onset of mental disorders."

Philip Wang, a HMS psychiatrist who was the lead investigator in the study of treatment, states, "Interventions are needed to improve the quality of care delivered to patients with mental disorders. Several disease management programs that enhance treatment adequacy and adherence have already been proven successful and cost-effective. Performance standards could further optimize quality and monitor the impact of future interventions."

Kessler also notes "initiatives are needed to increase the uptake of successful programs and treatment models. Widespread failure to disseminate proven interventions may, in fact, explain why large unmet need for treatment of mental disorders persists in the U.S. despite earlier efforts to address this problem."

About the Study

The NCS-R is a nationally representative survey of English-speaking household residents ages 18 and older in the United States. Ten thousand face-to-face interviews were carried out by professional interviewers between February 2001 and April 2003 using a survey tool developed by the World Health Organization that generates diagnoses for DSM-IV mental disorders.

The study was funded by the National Institute of Mental Health, with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the John W. Alden Trust.

LIST OF DISORDER TYPES AND A BREAKDOWN OF RESULTS

PREVALENCE, AGE-OF-ONSET, FAILURE, AND DELAY IN TREATMENT

ANXIETY DISORDERS