Understanding mental health treatment in persons without mental diagnoses: Results from the National Comorbidity Survey Replication

Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.
Archives of General Psychiatry (Impact Factor: 14.48). 11/2007; 64(10):1196-203. DOI: 10.1001/archpsyc.64.10.1196
Source: PubMed


Epidemiologic surveys have consistently found that approximately half of respondents who obtained treatment for mental or substance use disorders in the year before interview did not meet the criteria for any of the disorders assessed in the survey. Concerns have been raised that this pattern might represent evidence of misallocation of treatment resources.
To examine patterns and correlates of 12-month treatment of mental health or substance use problems among people who do not have a 12-month DSM-IV disorder.
Data are from the National Comorbidity Survey Replication, a nationally representative face-to-face US household survey performed between February 5, 2001, and April 7, 2003, that assessed DSM-IV disorders using a fully structured diagnostic interview, the World Health Organization Composite International Diagnostic Interview (CIDI).
A total of 5692 English-speaking respondents 18 years and older.
Patterns of 12-month service use among respondents without any 12-month DSM-IV CIDI disorders.
Of respondents who used 12-month services, 61.2% had a 12-month DSM-IV CIDI diagnosis, 21.1% had a lifetime but not a 12-month diagnosis, and 9.7% had some other indicator of possible need for treatment (subthreshold 12-month disorder, serious 12-month stressor, or lifetime hospitalization). The remaining 8.0% of service users accounted for only 5.6% of all services and even lower proportions of specialty (1.9%-2.4%) and general medical (3.7%) visits compared with higher proportions of human services (18.9%) and complementary and alternative medicine (7.6%) visits. Only 26.5% of the services provided to the 8.0% of presumably low-need patients were delivered in the mental health specialty or general medical sectors.
Most services provided for emotional or substance use problems in the United States go to people with a 12-month diagnosis or other indicators of need. Patients who lack these indicators of need receive care largely outside the formal health care system.

Download full-text


Available from: Harold Alan Pincus,
  • Source
    • "It is therefore important to increase our understanding of how people with subclinical depression will cope with their symptoms and what, if any, care will be sought. Future research should replicate the results from this study and expand knowledge by differentiating between people who suffer from first-time subclinical depression and people who report subclinical depression after having suffered from a depressive disorder as this is considered an indicator of need (Druss et al., 2007). This history of depression might influence whether or not people have experience with different types of care and this, in turn, might influence people's attitudes towards that care. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Although little is known about which people with subclinical depression should receive care to prevent the onset of depression, it is clear that remediating symptoms of depression is important. However, depending on the beliefs people hold about help, some people will seek professional help, while others seek informal help or solve problems on their own. This study examined associations between attitudes about help and socio-demographic variables, mastery, severity of depressive symptoms, accessibility to care, and health care utilization at baseline and 4-year follow-up. Data were derived from a large cohort study, the Netherlands Study of Depression and Anxiety (NESDA). A total of 235 respondents with subclinical depression completed questionnaires at baseline and follow-up. Attitude was assessed using a short version of the 'Trust in mental health care' questionnaire. Positive attitude towards professional care was associated with being male, younger age, higher mastery and easy accessibility to care. Positive attitude towards informal help was associated with higher mastery and unemployment. Older age, less accessibility to care and lower mastery were associated with positive attitude towards self-reliance. A change in care utilization was associated with positive attitudes towards professional care at follow-up. People differ in the way they cope with symptoms which may influence their preferred care. Higher levels of mastery were positively associated with professional and informal care, but negatively associated with self-reliance. Both age and mastery showed relatively large effect sizes. © The Author(s) 2015.
    International Journal of Social Psychiatry 08/2015; DOI:10.1177/0020764015597014 · 1.15 Impact Factor
  • Source
    • "One critical factor contributing to the excess morbidity and mortality seen in individuals with SMI is poor quality of medical care (Fleischhacker et al., 2008). For instance, research indicates that poor quality of care may explain as much as half of excess mortality after hospitalizations for myocardial infarction in this patient group (Druss et al., 2007). One of the potential solutions for poor quality of care received by this population lies in improved integration and coordination of mental health and primary care. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Individuals with serious mental illnesses (SMI) treated in the public mental health sector die decades younger than the general population. Poor quality and fragmentation of care are risk factors underlying the poor health of this population. Integrated electronic health records (EHR) can play a vital role in efforts to improve quality and outcomes of care in patients with SMI. The objective of this paper is to describe the current state of efforts to integrate and improve the mental and physical care of individuals with SMI in the public sector, with an emphasis on the use of electronic health records (EHR). While a range of encouraging initiatives exists throughout the country, technological and medico-legal challenges are providing significant barriers for the successful integration of care and EHRs for many partnering organizations. Furthermore, there is a lack of rigorous research studying the effectiveness and sustainability of these programmes. Recommendations are made for the alleviation of policy barriers and future areas of inquiry.
    International Review of Psychiatry 12/2014; 26(6):629-37. DOI:10.3109/09540261.2014.987221 · 1.80 Impact Factor
    • "Second, we examined the relationship between incident mental health service use and persistence of the same disorder , co-morbid disorder, or suicide attempt among individuals without a history of service use at baseline using x 2 tests of independence. It is possible that people with a DAS disorder that remitted without treatment at follow-up might have subthreshold symptoms that impair functioning (Druss et al. 2007 ; Pagura et al. 2011). Because of the methodology of the assessment of mental disorders at wave 2 in the NESARC, we could not estimate the number of people who had residual subthreshold symptoms of mental disorders. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Historically, meeting criteria for a mental disorder has been used as a proxy for the need for mental health services, yet research suggests that a significant proportion of disorders remit without treatment. In this study, risk factors for poor longitudinal outcomes of individuals with untreated common mental disorders were determined, with the goal of identifying individuals with unmet need and informing the development of targeted interventions. Methods: Data came from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey of the adult U.S. population (age ≥18; N=34,653). Respondents were assessed for past-year depressive, anxiety, and substance use disorders and mental health service use via face-to-face interviews conducted at two time points, three years apart. Among respondents without a history of mental health treatment, logistic regression analyses examined factors associated with persistence of the disorder, comorbidity, or suicide attempt (that is, presence of any axis I disorder in the past year at wave 2 or any suicide attempt during the follow-up) versus spontaneous recovery of baseline disorders. Results: Certain sociodemographic factors, comorbid mental disorders at baseline (such as three or more axis I disorders, adjusted odds ratio [AOR]=1.64, 95% confidence interval [CI]=1.27-2.12), and childhood maltreatment (AOR=1.47, CI=1.23-1.75) were predictors of disorder persistence, comorbidity, or suicide attempt in depressive, anxiety, and substance use disorders during the follow-up. Conclusions: In addition to considering the presence of a mental disorder, policy makers should consider other variables, such as childhood maltreatment and comorbidity, in estimating treatment need.
    Psychiatric Services 10/2014; DOI:10.1176/appi.ps.201300564 · 2.41 Impact Factor
Show more