Is the prevalence of mental disorders a good measure of the need for services?

Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys

BACKGROUND

Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment.

METHODS

Face-to-face household surveys were undertaken with 84,850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services.

FINDINGS

The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less.

INTERPRETATION

Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.

Population level of unmet need for mental healthcare in Europe

BACKGROUND

The high prevalence of mental disorders has fuelled controversy about the need for mental health services.

AIMS

To estimate unmet need for mental healthcare at the population level in Europe.

METHOD

As part of the European Study of Epidemiology of Mental Disorders (ESEMeD) project, a cross-sectional survey was conducted of representative samples of the adult general population of Belgium, France, Germany, Italy, The Netherlands and Spain (n=8796). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0. Individuals with a 12-month mental disorder that was disabling or that had led to use of services in the previous 12 months were considered in need of care.

RESULTS

About six per cent of the sample was defined as being in need of mental healthcare. Nearly half (48%) of these participants reported no formal healthcare use. In contrast, only 8% of the people with diabetes had reported no use of services for their physical condition. In total, 3.1% of the adult population had an unmet need for mental healthcare. About 13% of visits to formal health services were made by individuals without any mental morbidity.

CONCLUSIONS

There is a high unmet need for mental care in Europe, which may not be eliminated simply by reallocating existing healthcare resources.

Point prevalence of neurosis in the Lundby Study 1947-1997

The objective of this article is to report and discuss the changing point prevalence rate of neurosis 1947-1997 in the Lundby cohort. The Lundby Study is a prospective longitudinal study of a geographically defined total population in the south of Sweden. Field investigations were performed in 1947, 1957, 1972 and in 1997, with psychiatrists interviewing the probands in a semi-structured way. Additional information was gathered from registers, case notes and key informants. Throughout the period of 50 years, the Lundby Study used its own diagnostic system with neurosis referring to non-psychotic mental illness in the absence of an organic brain disease. After 1957, no newcomers were included, and therefore only probands 40 years of age or older at the cross-sectional surveys are included in the present paper. For men aged 40-59 and 60 years or older, respectively, the age-specific point prevalence of neurosis increased from 2.5% and 0.5% in 1947, to 8.3% and 8.4% in 1972. The corresponding figures for women were 8.0% and 1.3% in 1947, and 24.2% and 20.1% in 1972. The increase could be seen in all degrees of impairment, but it was most pronounced in the mild and medium impairment groups. Except for a slight decrease in point prevalence in the female group 40-59 years of age, there were no significant changes from 1972 to 1997. A large increase in the point prevalence rate of neurosis could be seen 1947-1972, but not 1972-1997. Because of the many biases inherent in longitudinal psychiatric studies, our results must be interpreted with caution.

A comment on the utility of prevalence estimates of pathological gambling

The case is presented that researchers interested in policy aimed at treating the pathological gambler need to shift focus to improving the utility of prevalence estimates. It is argued that researchers supplement prevalence estimates with practical and well-defined measures of severity and other predictors and correlates of help-seeking. The dimension of severity is emphasized as one means of providing estimates that are relevant to policy makers when placed in the context of additional measures that improve their meaning and utility. Estimates may then be partitioned along these dimensions to ascertain the proportion of gamblers most likely to need or seek treatment for gambling-related disorders. The recommendations provided are subject to a number of possible objections and are presented in the interest of stimulating further discussion such as the distinction between symptom assessment and the measurement of severity.

Perceived need for alcohol, drug, and mental health treatment

BACKGROUND

To investigate determinants of perceived need for alcohol, drug, and mental (ADM) health treatment and differences in ADM treatment patterns between individuals with perceived need and those without.

METHODS

We used data from a nationally representative telephone survey of 9585 adults conducted in 1997-1998. Logistic regression was used to study the determinants of perceived need and the correlation between perceived need and any ADM treatment, specialty ADM treatment, appropriate care, and medication adherence.

RESULTS

Just fewer than 37% of individuals with an ADM disorder perceived a need for treatment, while 4.6% of those without an ADM disorder perceived a need for treatment. Women, the young and middle aged, the better educated, those with greater emotional support, and those with greater psychiatric morbidity were more likely to perceive need for ADM services. Perceived need was strongly correlated with receiving ADM treatment, although almost 44% of individuals in ADM treatment did not perceive a need for treatment. Among individuals in ADM treatment, those with perceived need were significantly more likely to receive specialty ADM treatment, but not more likely to be treatment adherent, or to receive appropriate care.

CONCLUSION

Substantial levels of unmet need are likely to persist as long as perceived levels of need remain low. Interventions targeting perceived need may hold promise for decreasing unmet need.

Recognition and treatment recommendations for generalized anxiety disorder and major depressive episode: a cross-sectional study among general practitioners in norway

OBJECTIVE

Undertreatment by general practitioners (GPs) of patients who have generalized anxiety disorder (GAD) and major depressive episodes (MDEs) is well known. Overtreatment by GPs of patients without these disorders has received little attention. The aim of this study was to estimate GPs' recommended overtreatment (recommendation of treatment to patients who, on the basis of diagnostic self-ratings, had neither GAD nor MDE) and undertreatment (not recommending treatment to patients who, on the basis of self-ratings, had GAD or MDE) and to describe patient variables associated with overtreatment.

METHOD

In a cross-sectional design (during 3 consecutive days in September 2001), 136 Norwegian GPs evaluated 1332 patients. Diagnostic reference standards were patients' ratings of validated DSM-IV criteria-based questionnaires. GPs identified somatic diseases and mental disorders according to all accumulated information. For their diagnoses of MDE and GAD, the Clinical Global Impressions-Severity of Illness scale was used as a supplement, and GPs suggested treatment for these disorders.

RESULTS

The GPs recommended overtreatment in 11% (132/1245) of cases. The rates of under-treatment were 64% (18/28) and 49% (23/47) for GAD and MDE, respectively. For comorbid GAD and MDE the rate of undertreatment was 17% (2/12). Mental reason for patient's current visit and poor self-rated subjective health were strongly associated with overtreatment.

CONCLUSION

Our preliminary study indicates that overtreatment by GPs of patients who, according to self-rating, do not have GAD or MDE could represent a problem. Criteria-based diagnostic descriptions might be of limited relevance for the practice of GPs, and the issue of overtreatment should be investigated further in studies with improved design.

Suicidality, depression, and mental health service use in Canada

OBJECTIVE

To determine the magnitude of depression and suicidal populations, the overlap between these populations, and the associated patterns of mental health service use.

METHOD

We examined depression, suicidality (ideation and nonfatal behaviours), and the mental health service use of participants in the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being. The sample comprised 36 984 household members aged 15 years or over.

RESULTS

Approximately 4% to 5% of the population suffered from a major depression or suicidality. About 2 of 3 of those who were suicidal did not suffer from depression, and over 70% of those with depression did not report suicidality. Persons with depression and suicidality or depression (but no suicidality) were the 2 groups most likely to report ambulatory mental health contacts, and the provider groups contacted most often included physicians. The use of provider groups was considerably lower for those who were suicidal (but had no depression). Whereas the latter were more likely to report contacts than not, suicidality, in and of itself, did not exert a strong effect on contact with any particular provider group. For those who were suicidal (but who had no depression), less than 1 in 3 reported any mental health service contact, including an inpatient mental health stay.

CONCLUSIONS

The lack of contact by those who are suicidal (but who have no depression) is provocative, given that almost 2 of 3 of the suicidal subjects had no depression. Detrimental outcomes such as depression may develop without effective early interventions and uptake by a sufficient supply of appropriately trained and financially accessible personnel.

Perceived need for mental health treatment in a nationally representative Canadian sample

OBJECTIVE

The optimal method of determining how many people in the general population need help for emotional problems remains unclear. This study aimed to examine the prevalence and correlates of self-perceived need for mental health services (that is, help seeking and perceived need) in a large, population-based sample.

METHODS

Data came from the Canadian Community Health Survey 1.2 (n = 36,816, respondent age 15 years and over, and response rate 77%). Respondents were asked whether they had sought help in the past year from any professional for emotional problems and whether they felt they needed help for emotional symptoms but had not sought treatment. The Composite International Diagnostic Interview (CIDI) was used to make DSM-IV mental disorder diagnoses.

RESULTS

The past-year prevalences of help seeking and perceived need were 8.7% and 2.9%, respectively. After adjusting for the presence of DSM-IV disorders assessed in the survey, sociodemographic factors, illness severity, social supports, and the presence of physical health conditions were associated with help seeking and perceived need. Independent of DSM diagnoses, sociodemographics, and social supports, perceived need and help seeking were associated with increased levels of distress, disability, and suicidal ideation and attempts.

CONCLUSIONS

This study illustrates that, in addition to the presence of a DSM diagnosis, the respondent's self-perceived need for mental health treatment is important in the assessment of need for mental health services in the community.

Racial and ethnic differences in the mental health problems and use of mental health care

OBJECTIVES

We compared rates of mental health problems and use of mental health care across multiple racial and ethnic groups using secondary data from a large, nationally representative survey.

METHODS

We pooled cross-sectional data from the 2001-2003 National Surveys on Drug Use and Health. Our sample included 134,875 adults classified as white, African American, American Indian/Alaskan Native, Asian, Mexican, Central and South American, Puerto Rican, other Hispanic-Latino, or those with multiple race and ethnicities. For each group, we estimate the past year probability of: (1) having 1 or more mental health symptoms in the past year, (2) having serious mental illness in the past year, (3) using mental health care, (4) using mental health care conditional on having mental health problems, (5) reporting unmet need for mental health care, and (6) reporting unmet need for mental health care conditional on having mental health problems.

RESULTS

We found significantly higher rates of mental health problems and higher self-reported unmet need relative to whites among American Indian/Alaskan Natives and lower rates of mental health problems and use of mental health care among African American, Asian, Mexican, Central and South American, and other Hispanic-Latino groups. These differences generally were robust to the inclusion of clinical and socio demographic covariates.

CONCLUSIONS

Overall, our study shows wide variation in mental health morbidity and use of mental health care across racial and ethnic groups in the United States. These results can help to focus efforts aimed at understanding the underlying causes of the differences we observe.

Prevalence and treatment of mental disorders, 1990 to 2003

BACKGROUND

Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders.

METHODS

We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services.

RESULTS

The prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents.

CONCLUSIONS

Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments.

Sad, blue, or depressed days, health behaviors and health-related quality of life, Behavioral Risk Factor Surveillance System, 1995-2000

Background

Mood disorders are a major public health problem in the United States as well as globally. Less information exists however, about the health burden resulting from subsyndromal levels of depressive symptomatology, such as feeling sad, blue or depressed, among the general U.S. population.

Methods

As part of an optional Quality of Life survey module added to the U.S. Behavioral Risk Factor Surveillance System, between 1995–2000 a total of 166,564 BRFSS respondents answered the question, "During the past 30 days, for about how many days have you felt sad, blue, or depressed?" Means and 95% confidence intervals for sad, blue, depressed days (SBDD) and other health-related quality of life (HRQOL) measures were calculated using SUDAAN to account for the BRFSS's complex sample survey design.

Results

Respondents reported a mean of 3.0 (95% CI = 2.9–3.1) SBDD in the previous 30 days. Women (M = 3.5, 95% CI = 3.4–3.6) reported a higher number of SBDD than did men (M = 2.4, 95% CI = 2.2–2.5). Young adults aged 18–24 years reported the highest number of SBDD, whereas older adults aged 60–84 reported the fewest number. The gap in mean SBDD between men and women decreased with increasing age. SBDD was associated with an increased prevalence of behaviors risky to health, extremes of body mass index, less access to health care, and worse self-rated health status. Mean SBDD increased with progressively higher levels of physically unhealthy days, mentally unhealthy days, unhealthy days, activity limitation days, anxiety days, pain days, and sleepless days.

Conclusion

Use of this measure of sad, blue or depressed days along with other valid mental health measures and community indicators can help to assess the burden of mental distress among the U.S. population, identify subgroups with unmet mental health needs, inform the development of targeted interventions, and monitor changes in population levels of mental distress over time.

The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)

This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.