Psychiatr News March 17, 2006
Volume 41, Number 6, page 3
© 2006 American Psychiatric Association
Prevalence, Treatment Data Raise Troubling Questions
Steven Sharfstein, M.D.
How many Americans suffer from symptoms of psychiatric disorders in a year?
How many people have psychiatric disorders whose symptoms are serious and
disabling? What proportion of these people receive adequate treatment? These
and other critical questions for the practice of psychiatry have been
addressed in an elaborate and far-reaching study in the "National
Comorbidity Survey Replication" conducted by Ron Kessler and colleagues
and published in a series of three papers last June in the Archives of
General Psychiatry.
This study involved detailed interviews with nearly 9,300 randomly chosen
American adults, representative of persons in the general U.S. population,
between February 2001 and April 2003. The results indicated that 26 percent of
respondents reported having symptoms sufficient for diagnosing a mental
disorder in the previous 12 months. Not surprisingly, prevalence estimates
were highest for anxiety disorders at 18 percent, and then mood disorders at
nearly 10 percent (Psychiatric News, July 15, 2005).
These rates of disorder are consistent with the rates found in the previous
survey a decade ago. In the recent study period, as there have been no
"cures" developed for psychiatric disorders, the lack of change in
basic prevalence is not surprising. However, it is important and desirable to
be able to document a decrease in disability and the burden of disease as our
psychiatric treatment continues to improve. I believe many patients are
"better, but not well" as Gerald Klerman, M.D., put it.
In terms of the severity of psychiatric symptoms, most of the respondents
identified as having a psychiatric disorder had symptoms that were considered
to be in the mild (41 percent of disorders) or moderate (37 percent of
disorders) range, while fewer persons had symptoms that were considered to be
in the serious range (22 percent of disorders and 6 percent of the total
population sample).
The findings about treatment are most illuminating. Of the people
identified as having a psychiatric disorder in the past 12 months, close to 60
percent had not received any treatment for their disorder. Among those who
sought treatment (approximately 40 percent), close to one-third did so with
unproven therapies, such as dietary supplements or acupuncture. Of those who
sought traditional care for their psychiatric problems, the largest number was
treated by general medical providers, not psychiatric or mental health
specialists. In fact, psychiatrists treated only 12 percent of cases
identified as having a psychiatric disorder.
The proportion of the population treated for mental illness over a 12-month
period, some of whom did not meet the threshold for a psychiatric diagnosis,
has grown to 17 percent from 13 percent a decade ago. This expansion was
mainly in the general medical sector, with more primary care physicians
providing psychiatric services and psychiatric medications than in the
past.
Most distressing to me was the general inadequate level of care that
persons received for their psychiatric disorders. Only 13 percent seen for
mental health problems by general medical providers received minimally
adequate care (defined as receiving either at least two months of an
appropriate medication for a focal disorder plus four visits to the physician
or with a health care or human services professional for psychotherapy lasting
an average of 30 minutes a session). The care was better when provided by
psychiatrists; but only 48 percent of those who went to psychiatrists received
care that met minimal standards.
These minimally adequate treatment standards set at levels consistent with
general levels of treatment guidelines do not answer the question, What are
the results of these treatments? More attention is needed to assess treatment
outcome in terms of both symptoms as well as functional abilities in the
everyday lives of our patients as we make the case for more resources to
provide these treatments.
Another important issue this study investigated is the age of onset of
psychiatric disorders and the delay in seeking help or treatment. Half of
those identified as having a psychiatric disorder reported showing signs of
illness by age 14; three-quarters reported showing signs by age 24. Delays for
treatment ranged from an average of nine to 23 years for anxiety disorders and
six to eight years for mood disorders.
The study raises many questions and issues about the nature of psychiatric
disorders and the role of psychiatrists. Does our DSM nosology have
too low a threshold in selecting symptoms of mental disorders? Many of these
disorders may be self-limiting and mild in response to life stresses. As noted
by Dr. Kessler in a recent NPR interview, how much credibility does our
diagnostic system lose by attaching a psychiatric diagnosis to these
relatively mild and self-limiting problems? Should all people who meet
criteria for a disorder receive psychiatric treatment? How do we decide which
ones should receive treatment and what kind? Who and how many should be seen
by psychiatrists for treatment? Most important for psychiatry, if only a small
minority of persons with a serious psychiatric disorder receives care that
meets even basic treatment standards, what are the implications for our
profession? What can we do to address this problem?
We need to have state-of-the-art performance measures for assessing
individual clinical care in psychiatry. All the rhetoric around
"evidence-based medicine" aside, without such, we do not know how
well we are doing for our patients.
It is clear that there is an unmet need for treatment. There are far too
few psychiatrists to meet that need. Barriers to care remain high. Continued
improvements in psychiatric treatment need to translate to better outcomes.
Better outcomes will enhance our case for nondiscriminatory insurance
coverage. Let's hope that in another 10 years when this study is once again
replicated, we will have made significant progress on all of these fronts.
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