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Survey shows
mixed results
(August/September
2005 Issue)
By Nan Shnitzler
While the last decade has seen advances in mental health awareness,
access and therapies, Americans still suffer mental disorders that
in many cases begin in adolescence and remain inadequately treated,
according to the National Comorbidity Survey Replication (NCS-R)
results published in four papers in the June Archives of General
Psychiatry. The survey was a collaboration of Harvard University,
University of Michigan and the National Institute of Mental Health
(NIMH).
The recent survey is an expanded version of the 1990 National Comorbidity
Survey, the first to use modern psychiatric standards to assess
mental disorders in a nationally representative sample, according
to NIMH. NCS-R is based on face-to-face household interviews of
9,282 randomly selected English-speaking adults between Feb. 2001
and April 2003 using a survey tool developed by the World Health
Organization that generates diagnoses for DSM-IV mental disorders.
The survey examined prevalence, severity, age of onset, comorbidity
and quality of care for four disorders: anxiety, impulse-control,
mood and substance abuse.
"The study confirms a growing understanding about the nature of
mental illness across the lifespan," says Thomas Insel, M.D., director
of NIMH that funded the $20 million study along with the National
Institute of Drug Abuse, the Substance Abuse and Mental Health Services
Administration (SAMHA), the Robert Wood Johnson Foundation and the
John W. Alden Trust.
Overall, researchers report that nearly half the population will
meet diagnostic criteria for a mental health disorder at some point
in their lives, that six percent will become severely debilitated,
that mental illness begins by age 14 in half of all lifetime cases,
that long delays transpire between symptom onset and treatment seeking
and that quality of treatment is often poor.
The survey sample did not include institutionalized and homeless
individuals nor did it review relatively rare and complex disorders
such as autism and schizophrenia, limitations the researchers acknowledge.
"Research over the last 30 years shows that there is a high degree
of stability in the prevalence of mental disorders in the adult
population," says Ronald W. Manderscheid, Ph.D., survey and analysis
branch chief for the federal Center for Mental Health Services.
This new work, he says, helps identify population subgroups, for
example, those whose disorders progress from mild to severe.
Survey results show lifetime prevalence of any disorder at 46.4
percent. Anxiety disorders, suffered by 28.8 percent of adults at
some point in their lives, and impulse-control disorders, by 24.8
percent, had the earliest age of onset, 11 years. Lifetime prevalence
of mood and substance abuse disorders were 20.8, and 14.6 percent,
respectively. Mood disorders had the latest age of onset, 30 years.
About 45 percent of those with one mental disorder met criteria
for two or more disorders with severity strongly related to comorbidity.
Mental health risk was lowest among older adults, leading the researchers
to write, "Whatever else we can say about mental disorders, they
are distinct from chronic physical disorders because they have their
strongest foothold in youth."
"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 intervention to children," says Ronald
C. Kessler, Ph.D., Harvard Medical School professor of health care
policy, who directed both national surveys.
Data from a parallel study of 10,000 adolescents, NCS-A, will not
be available for about a year, but existing data shows that without
intervention, mild conditions during adolescence can develop into
serious disorders by early adulthood.
"If those teens aren't seen for 10 years, they miss a window of
opportunity and the problems have gotten much worse," Manderscheid
says. "There are both cost and quality of life implications in not
addressing them earlier.
The good news, says Philip S. Wang, M.D., Dr.P.H., department
of health care policy, Harvard Medical School, is that there appears
to be increasing use of primary care treatment for mental disorders.
The proportion of those receiving mental health services in the
12 months before the survey was 17.9 percent, up from 13.3 percent
a decade earlier.
The bad news, Wang says, is that most sufferers did not receive
treatment in the prior year and if they did, it was below minimum
guidelines established by researchers: appropriate medication and
four physician visits for pharmacotherapy and eight visits to any
provider for psychotherapy.
"What we found was, surprisingly, of those getting treatment, the
treatments are not achieving these minimal standards we defined,"
Wang says.
In extreme cases, inadequate care can be dangerous, says Kathleen
R. Merikangas, Ph.D., NIMH senior investigator. The wrong medication
coupled with insufficient follow up can unleash manifestations of
mental illness to the point that patients become incapacitated.
"The point is to treat the patient, not the disorder," Merikangas
says, to help patients cope in a way that gets them functional and
back in their life roles, reducing the social and economic burden
of mental illness.
Understanding the epidemiology of mental disorders helps plan for
treatment of disorders, even common ones, that can affect people
to the point of impairment or disability, Merikangas says.
Researchers over the past decade have been fairly successful in
devising model programs and successful interventions that work and
are cost effective, Wang says. The issue is getting health plans
to implement them and employers to purchase them.
"We don't have to start from scratch to figure out treatment,"
Wang says.
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