Do adults receive adequate treatment for mental disorders?

Among community-dwelling adults surveyed between 2001 and 2003 who received any treatment for a mental disorder in the past year, only one of three (33%) received minimally adequate treatment. Mental health specialists were more likely than general practitioners to provide adequate treatment.

Why is this important?

• One of every four adults in the U.S.—about 58 million Americans—experience a diagnosable mental illness during the course of a year. Almost one-quarter of these individuals suffer from a serious mental illness and almost one-half have more than one type of disorder (Kessler et al. 2005).
• Mental illnesses are a leading cause of disability worldwide (WHO 2001). The cost to the U.S. economy in lost productivity is likely to exceed treatment costs (Hu 2006), which totaled $104 billion in 2001 for mental health and substance abuse services (Mark et al. 2005). Depression alone costs employers more than $30 billion in lost productive work time annually (Stewart et al. 2003).
• A review of evidence-based guidelines and research suggests that minimally adequate treatment for mental disorders should consist of at least two months of appropriate medication plus at least four physician visits during treatment, or at least eight psychotherapy sessions lasting at least 30 minutes each (Wang et al. 2002; Wang et al. 2005).

Findings

Among community-dwelling adults (ages 18 and older) surveyed between 2001 and 2003 who received any treatment for a diagnosable mental disorder during the past year, two of three did not receive a minimally adequate level of treatment to help ensure good outcomes (Wang 2002).

• Only about one-half of patients treated by mental health specialists (such as psychiatrists and psychologists) received minimally adequate treatment.
• Seven of eight patients treated by general practitioners (such as primary care physicians and nurses) did not receive minimally adequate treatment.
• Patients treated for anxiety or mood disorders were somewhat more likely to receive minimally adequate treatment than were those treated for impulse control or substance abuse disorders.

Implications

• Contributing causes of poor quality might include inadequate training and experience in effective mental health treatment, insufficient clinical time and reimbursement for services, and inadequate patient education and adherence (Wang et al. 2005).
• Experts who have examined the quality of mental health care concluded that "[s]pending the additional 20–30 percent it takes for care following practice guidelines could quadruple the cost-effectiveness of mental health care, or the return on each dollar spent on care, in terms of improving patients' ability to function on the job and around the house" (RAND 1998).

Improvement Ideas and Resources

Care management interventions have demonstrated improved quality and outcomes of care for adults with mental illnesses including depression (Gilbody et al. 2003), schizophrenia (Stein and Santos 1998), panic and generalized anxiety disorders (Rollman et al. 2005), and bipolar disorder (Simon et al. 2005). Common elements include a collaborative care approach involving an enhanced role for nurses and skills training or supports for local practitioners. Positive outcomes have included increased employment retention and reduced absenteeism among depressed working adults (Rost et al. 2004; Wells et al. 2000).Mental health experts propose coordinated effort among stakeholders to address systemic issues affecting quality of mental health care. Strategies might include:

• leveraging market incentives and engaging professional leadership to promote training and competency in effective care practices and spread the adoption of evidence-based quality standards (Patel et al. 2006).
• making interventions more feasible for adoption in everyday practice by targeting them to more severe or complex cases, integrating them with other disease management programs using shared resources, and demonstrating their value for improving workplace productivity (Oxman et al. 2005).

Measure:

The denominator includes community-dwelling adults ages 18 and older with a mental disorder that met the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) who reported receiving any mental health services during the preceding 12 months (Wang et al. 2006). Mental disorders included the following:

• mood disorders: bipolar I and II disorders, major depressive disorder, and dysthymia;
• anxiety disorders: panic disorder, agoraphobia without panic, specific phobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and separation anxiety disorder;
• impulse control disorder: intermittent explosive disorder; and
• substance disorders: alcohol and other drug abuse and dependence.

The numerator contains the subset of the denominator population who received at least two months of appropriate medication plus at least four physician visits during treatment, or at least eight psychotherapy sessions of at least 30 minutes duration. If a patient had more than one disorder, each was evaluated separately. Results were stratified by the type of health professional as follows:

• Mental health specialists included psychiatrists, psychologists or other nonpsychiatrist mental health professionals in any setting, social workers or counselors in a mental health setting, or use of a mental health hotline.
• General medical providers included primary care physicians, other general physicians and nurses, or any other health care professional not previously mentioned.

Note: About 13 percent of adults with mental disorders received treatment from non-health care professionals including human services professionals or complementary and alternative medicine providers (treatment in these settings is not included in the data shown).

Limitations:

The measure of treatment adequacy used in this study has not been validated. The adequacy of treatment did not distinguish between newly diagnosed and prevalent cases and was not analyzed by severity of illness. The study did not measure how often general practitioners referred patients to mental health specialists for treatment. Self-reported service use data are subject to potential recall bias.

Source:

Data were compiled by researchers at Harvard Medical School, Columbia University, the University of Pittsburgh, and the University of California, Los Angeles, based on responses to the National Comorbidity Survey Replication, a national, face-to-face household survey that includes the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Results were weighted to be representative of the U.S. civilian, noninstitutionalized population (Wang et al. 2006).

References:

* Indicates source of data used in the chart(s).Gilbody, S., P. Whitty, J. Grimshaw et al. 2003. Educational and Organizational Interventions to Improve the Management of Depression in Primary Care: A Systematic Review. Journal of the American Medical Association 289 (23): 3145–51.

Hu, T.-w. 2006. An International Review of the National Cost Estimates of Mental Illness, 1990–2003. The Journal of Mental Health Policy and Economics 9 (1): 3–13.

Kessler, R. C., W. T. Chiu, O. Demler et al. 2005. Prevalence, Severity, and Comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6): 617–27.

Mark, T. L., R. M. Coffey, D. R. McKusick et al. 2005. National Expenditures for Mental Health Services and Substance Abuse Treatment 1991–2001. SAMHSA Publication No. SMA 05-3999. Rockville, Md.: Substance Abuse and Mental Health Services Administration.

Oxman, T. E., A. J. Dietrich, and H. C. Schulberg. 2005. Evidence-Based Models of Integrated Management of Depression in Primary Care. The Psychiatric Clinics of North America 28 (4): 1061–77.

Patel, K. K., B. Butler, and K. B. Wells. 2006. What is Necessary to Transform the Quality of Mental Health Care. Health Affairs (Millwood) 25 (3): 681–93.

RAND. 1998. Improving the Quality and Cost-Effectiveness of Treatment for Depression. RB-4500-1. Santa Monica, Calif.: RAND Health.

Rollman, B. L., B. H. Belnap, S. Mazumdar et al. 2005. A Randomized Trial to Improve the Quality of Treatment for Panic and Generalized Anxiety Disorders in Primary Care. Archives of General Psychiatry 62 (12): 1332–41.

Rost, K., J. L. Smith, and M. Dickinson. 2004. The Effect of Improving Primary Care Depression Management on Employee Absenteeism and Productivity. A Randomized Trial. Medical Care 42 (12): 1202–10.

Simon, G. E., E. J. Ludman, J. Unutzer et al. 2005. Randomized Trial of a Population-Based Care Program for People with Bipolar Disorder. Psychological Medicine 35 (1): 13–24.

Stein, L. I., and A. B. Santos. 1998. Assertive Community Treatment of Persons with Severe Mental Illness. New York: Norton.

Stewart, W. F., J. A. Ricci, E. Chee et al. 2003. Cost of Lost Productive Work Time Among US Workers with Depression. Journal of the American Medical Association 289 (23): 3135–44.

* Wang, P. S., O. Demler, and R. C. Kessler. 2002. Adequacy of Treatment for Serious Mental Illness in the United States. American Journal of Public Health 92 (1): 92–8.

Wang, P. S., M. Lane, M. Olfson et al. 2005. Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6): 629–40.

Wells, K. B., C. Sherbourne, M. Schoenbaum et al. 2000. Impact of Disseminating Quality Improvement Programs for Depression in Managed Primary Care: A Randomized Controlled Trial. Journal of the American Medical Association 283 (2): 212–20.

WHO (World Health Organization). 2001. The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: World Health Organization.