How many adults with probable serious mental illness do not receive mental health care? How many report cost-related barriers to treatment?

In 2005, more than one-half (55%) of adults who experienced serious psychological distress indicative of serious mental illness did not receive mental health care in the past year. Among those who perceived that they had an unmet need for treatment, cost or inadequate insurance coverage was most often cited as a reason for not obtaining treatment.

Why is this important?

Mental illnesses constitute a leading cause of disability in the United States (WHO 2001). Untreated and inadequately treated mental illness has adverse personal and societal consequences that "are felt directly in the workplace; in the education, welfare, and justice systems; and in the nation's economy as a whole" (IOM 2006).

Serious mental illnesses "almost always lead to serious impairment if they are not treated" (Kessler et al. 2001). Although most people with mental illnesses eventually seek treatment, delay in care-seeking typically ranges from four to 23 years from the onset of disorders (Wang et al. 2005). Treatment delay is associated with poorer outcomes (Norman et al. 2005).

Many patients have co-occurring physical and mental illnesses, which can adversely affect health habits, treatment adherence, and outcomes (Katon 2003). Because these patients tend to make greater use of health care, it is possible that improved access and coordination of care might reduce overall utilization of services for these individuals (Himelhoch et al. 2004).

Findings

In 2005, 25 million community-dwelling U.S. adults ages 18 and older—about 11 percent of the adult population—reported symptoms of serious psychological distress in the past year, indicating a high probability that they suffered from a serious mental illness and could benefit from mental health evaluation or treatment (SAMHSA 2006). Among these individuals:

• Less than one-half (45%) reported that they received any mental health treatment or counseling in the past year.
• Receipt of treatment was lowest among men (37%) and younger adults ages 18 to 25 (31%).

Among a subset of those with serious psychological distress in the past year who received no treatment in the past year and reported an unmet need for treatment in the past year:

• Cost or insurance barriers were cited by more than one-half (54%) as a reason for not obtaining treatment.
• Almost one-third (32%) apparently didn't perceive the need for treatment at the time that they had the problem (but had recognized a need for treatment by the time of the survey).
• Other major reasons for not obtaining treatment included stigma (26%), not knowing where to go (22%), and not having time (17%).

Implications

About 13 million adults were not treated for probable serious mental illnesses in 2005. Many adults with mental illness do not perceive that they have a problem or need treatment (Kessler et al. 2001). Policymakers must consider the relative merits of targeting resources toward screening and education to raise awareness of need and reduce stigma associated with treatment, and improving access and coverage for those who do perceive a need for treatment.

The proportion of working-age U.S. adults (ages 18 to 54) with diagnosable serious mental illnesses who received any type of mental health services in the previous year increased from 24 percent in 1990–1992 to 41 percent in 2001–2003 (Kessler et al. 2005). However, the proportion of adults with probable serious mental illness who reported cost-related unmet need also increased from 1997 to 2002 (Mojtabai 2005), suggesting that access to care is not keeping step with a greater awareness of need.

Improvement Ideas and Resources

Recent reports by the U.S. Surgeon General (DHHS 1999), the Institute of Medicine (IOM 2006), and the President's New Freedom Commission on Mental Health (PNFCMH 2003) have identified problems such as fragmentation and inefficiencies in mental health services and strategies to overcome them. The President's Commission set the following six goals for transforming the nation's mental health care system:

1. Americans understand that mental health is essential to overall health.
2. Mental health care is consumer- and family-driven.
3. Disparities in mental health services are eliminated.
4. Early mental health screening, assessment, and referral to services are common practices.
5. Excellent mental health care is delivered and research is accelerated.
6. Technology is used to access mental health care information.

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) provides block grants to states to fund services for individuals with serious mental illness who cannot afford private care. In collaboration with the states, SAMHSA has begun reporting annually on National Outcomes Measures for the prevention and treatment of substance use and mental disorders. Many states are seeking to improve the efficiency and effectiveness of their mental health services through varied and innovative approaches (Perlman and Dougherty, 2006).

Measure:

Serious psychological distress (SPD) was defined as having a score of 13 or higher (on a scale from 0 to 24) on the K6 screening instrument. Research suggests that scores above this threshold indicate a high probability of having serious mental illness (Kessler et al. 2002; 2003). The National Survey of Drug Use and Health (NSDUH) measured SPD during the one month in the past 12 months when respondents were at their worst emotionally.

A serious mental illness (SMI) is a diagnosable mental, behavioral, or emotional disorder that meets the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV or the ICD-9-CM equivalent) and results in functional impairment that substantially interferes with or limits one or more major life activities. SMI does not include substance use or developmental disorders unless they co-occur with SMI (Federal Register 58(96):29422-5).

Treatment for mental health problems was defined as "treatment or counseling for any problem with emotions, nerves, or mental health in the 12 months prior to the interview in any inpatient or outpatient setting, or the use of prescription medication for treatment of a mental or emotional condition." Respondents were asked to exclude treatment for substance use, which was asked about in a separate part of the survey. Respondents with unknown treatment/counseling information were excluded from the analysis (SAMHSA 2006).

Limitations:

The K6 screening instrument used in these surveys has low sensitivity but high specificity, meaning that "many cases of serious mental illness may not be detected [but] the vast majority of the cases that are detected would meet [diagnostic criteria] for serious mental illness" (Mojtabai 2005). Some individuals with mental health problems seek services outside the health care system; such services are not included in treatment data shown in the chart.

Note: Rates of treatment for serious psychological distress from the 2005 NSDUH are not comparable to previous NSDUH reports or the 2005 National Healthcare Quality Report, which reported rates of treatment for serious mental illness using a slightly different methodology.

Source:

The National Survey of Drug Use and Health is an annual, nationally representative in-person interview survey of the U.S. civilian, noninstitutionalized population ages 12 and older (results are reported only for adults ages 18 and older). Data were compiled by the Substance Abuse and Mental Health Services Administration's Office of Applied Studies and RTI International.

References:

* Indicates source of data used in the chart(s).

DHHS (Department of Health and Human Services). 1999. Mental Health: A Report of the Surgeon General. Rockville, Md.: National Institute of Mental Health, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

Himelhoch, S., W. E. Weller, A. W. Wu et al. 2004. Chronic Medical Illness, Depression, and Use of Acute Medical Services Among Medicare Beneficiaries. Medical Care 42 (6): 512–21.

IOM (Institute of Medicine). 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, D.C.: National Academies Press.

Katon, W. J. 2003. Clinical and Health Services Relationships between Major Depression, Depressive Symptoms, and General Medical Illness. Biological Psychiatry 54 (3): 216–26.

Kessler, R. C., G. Andrews, L. J. Colpe et al. 2002. Short Screening Scales to Monitor Population Prevalences and Trends in Non-Specific Psychological Distress. Psychological Medicine 32 (6): 959–76.

Kessler, R. C., P. R. Barker, L. J. Colpe et al. 2003. Screening for Serious Mental Illness in the General Population. Archives of General Psychiatry 60 (2): 184–9.

Kessler, R. C., P. A. Berglund, M. L. Bruce et al. 2001. The Prevalence and Correlates of Untreated Serious Mental Illness. Health Services Research 36 (6 Pt 1): 987–1007.

Kessler, R. C., O. Demler, R. G. Frank et al. 2005. Prevalence and Treatment of Mental Disorders, 1990 to 2003. New England Journal of Medicine 352 (24): 2515–23.

Mojtabai, R. 2005. Trends in Contacts with Mental Health Professionals and Cost Barriers to Mental Health Care Among Adults with Significant Psychological Distress in the United States: 1997–2002. American Journal of Public Health 95 (11): 2009–14.

Norman, R. M., S. W. Lewis, and M. Marshall. 2005. Duration of Untreated Psychosis and Its Relationship to Clinical Outcome. British Journal of Psychiatry Supplement 48: s19–23.

Perlman, S. B., and R. H. Dougherty. 2006. State Behavioral Health Innovations: Disseminating Promising Practices. New York: The Commonwealth Fund.

PNFCMH (President's New Freedom Commission on Mental Health). 2003. Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, Md.: New Freedom Commission on Mental Health.

* SAMHSA (Substance Abuse and Mental Health Services Administration). 2006. Results from the 2005 National Survey on Drug Use and Health: National Findings. NSDUH Series H-30, DHHS Publication No. SMA 06-4194. Rockville, Md.: U.S. Department of Health and Human Services.

Wang, P. S., P. Berglund, M. Olfson et al. 2005. Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6): 603–13.

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