Consumer Affairs News from the Center for Mental
Health Services
http://www.mentalhealth.samhsa.gov/consumersurvivor/___________________________________________________
CMHS Consumer Affairs E-News June 7, 2005 Vol.
05-86
___________________________________________________
NIMH: Mental Illness Exacts Heavy Toll, Beginning
in Youth
Researchers supported by the National Institute
of Mental Health (NIMH) have found that half of
all lifetime cases of mental illness begin by age
14, and that despite effective treatments, there
are long delays - sometimes decades - between
first onset of symptoms and when people seek and
receive treatment. The study also reveals that an
untreated mental disorder can lead to a more severe,
more difficult to treat illness, and to the
development of co-occurring mental illnesses.
The landmark study is described in four papers
that document the prevalence and severity of
specific mental disorders. The papers provide
significant new data on the impairment - such as days lost
from work - caused by specific disorders,
including mood, anxiety, and substance abuse disorders.
These measures will allow researchers to
determine the degree of disability and the economic
burden caused by mental illness, as well as trends
over time.
The papers are reported in the June 6 issue of
the Archives of General Psychiatry by Ronald
Kessler, Ph.D., and colleagues. The study was a
collaborative project between Harvard University, the
University of Michigan, and the NIMH Intramural
Research Program.
This study, called the National Comorbidity
Survey Replication (NCS-R), is a household survey of
9,282 English-speaking respondents, age 18 and
older. It is an expanded replication of the 1990
National Comorbidity Survey, which was the first to
estimate the prevalence of mental disorders
(using modern psychiatric standards) in a nationally
representative sample. The expansion includes
detailed measures that will significantly improve
estimates of the severity and persistence of mental
disorders, and the degree to which they impair
individuals and families, and burden employers and
the U.S. economy.
"These studies confirm a growing understanding
about the nature of mental illness across the
lifespan," says Thomas Insel, M.D., Director of the
National Institute of Mental Health. "There are
many important messages from this study, but perhaps
none as important as the recognition that mental
disorders are the chronic disorders of young
people in the U.S."
Prevalence and Age-of-Onset of Mental Disorders
Unlike most disabling physical diseases, mental
illness begins very early in life. Half of all
lifetime cases begin by age 14; three quarters have
begun by age 24. Thus, mental disorders are
really the chronic diseases of the young. For example,
anxiety disorders often begin in late childhood,
mood disorders in late adolescence, and substance
abuse in the early 20's. Unlike heart disease or
most cancers, young people with mental disorders
suffer disability when they are in the prime of
life, when they would normally be the most
productive.
The risk of mental disorders is substantially
lower among people who have matured out of the
high-risk age range. Prevalence increases from the
youngest group (age 18-29) to the next-oldest age
group (age 30-44) and then declines, sometimes
substantially, in the oldest group (age 60 +).
Females have higher rates of mood and anxiety
disorders. Males have higher rates of substance use
disorders and impulse disorders.
The survey found that in the U.S., mental
disorders are quite common; 26 percent of the general
population reported that they had symptoms
sufficient for diagnosing a mental disorder during the
past 12 months. However, many of these cases are
mild or will resolve without formal interventions.
It is likely, however, that the prevalence rates
in this paper are underestimated, because the
sample was drawn from listings of households and did
not include homeless and institutionalized
(nursing homes, group homes) populations. In addition,
the study did not assess some rare and clinically
complex psychiatric disorders, such as
schizophrenia and autism, because a household survey is not
the most efficient study design to identify and
evaluate those disorders.
Failure and Delay in Initial Treatment Contact
The study documents the long delays between the
onset of a mental disorder and the first treatment
contact, as well as the accumulated burden and
hazards of untreated mental disorders.
These pervasive delays in getting treatment tend
to occur for nearly all mental disorders, though
they vary according to specific diagnostic
categories. The median delay across disorders is nearly
a decade; the longest delays are 20-23 years, for
social phobia and separation anxiety disorders.
This is possibly due to the relatively early age
of onset and fears of therapy that involve social
interactions.
Shorter delays between onset of disorder and
treatment seeking - still a protracted 6-8 years -
are seen for mood disorders, and are likely
attributable to public awareness campaigns, the
marketing of newer therapies directly to consumers, and
expanded insurance coverage.
While approximately 80 percent of all people in
the U.S. with a mental disorder eventually seek
treatment, there are public health implications
from such long delays in treatment. Untreated
psychiatric disorders can lead to more frequent and
more severe episodes, and are more likely to become
resistant to treatment. In addition, early-onset
mental disorders that are left untreated are
associated with school failure, teenage childbearing,
unstable employment, early marriage, and marital
instability and violence.
"The pattern appears to be that the earlier in
life the disorder begins, the slower an individual
is to seek therapy, and the more persistent the
illness," said Dr. Kessler, a professor of health
care policy at Harvard Medical School. "It's
unfortunate that those who most need treatment are
the least likely to get it."
Treating cases early could prevent enormous
disability, before the illness becomes more severe,
and before co-occurring mental illnesses develop,
which only become more difficult to treat as they
accumulate, according to the researchers.
Severity and Comorbidity of Mental Disorders
The second paper reports that even though mental
disorders are widespread throughout the
population, the main burden of illness is concentrated in
those with a severe disorder - about 6 percent. A
"serious" disorder involves a substantial
limitation in daily activities or work disability, or a
suicide attempt with serious lethal intent, or
psychosis. The serious group reported a mean of
88.3 days - nearly 3 months of the year - when they
were unable to carry out their normal daily
activities.
Unfortunately, say the researchers, individuals
with one mental disorder are at a high risk for
also having a second one (comorbidity). Nearly half
(45 percent) of those with one mental disorder
met criteria for two or more disorders, with
severity strongly related to comorbidity. This finding
supports the suggestion by a growing portion of
researchers that the boundaries between some
diagnostic categories may be less discrete than
previously believed.
Use of Mental Health Services
The study indicates that the U.S. mental health
care system is not keeping up with the needs of
consumers and that improvements are needed to speed
initiation of treatment as well as enhance the
quality and duration of treatment. For instance,
over a 12-month period, 60 percent of those with a
mental disorder got no treatment at all.
The good news is that the proportion of people
who reported 12-month mental health service use is
higher now - at 17 percent - than a decade ago in
the baseline NCS survey, at 13 percent. The
expansion was mainly in the general medical sector,
with more primary care physicians providing
psychiatric services.
People with mental or substance abuse disorders
were more likely to get treatment from a primary
care physician/nurse or other general medical
doctor (22.8 percent), or from a non-psychiatrist
mental health specialist (16 percent), such as a
psychologist, social worker, or counselor, than from
a psychiatrist (12 percent), though the survey
did show that the adequacy of treatment - measured
by number of visits - is best when provided by
mental health practitioners. About 9.7 percent
sought help from a counselor or spiritual advisor
outside of a mental health setting; and 6.9 percent
used a complementary-alternative source, such as
a chiropractor or self-help group. This held true
even for those with severe mood disorders.
Traditionally underserved groups, such as the elderly,
racial/ethnic minorities and those with low
income or without insurance, had the greatest unmet
need for treatment.
Future and Ongoing Efforts
The NIMH epidemiological research portfolio
contains several related projects that are focused on
mental disorders among adolescents and ethnic
subgroups. These include 1) an arm of the NCS-R that
is studying 10,000 youths; 2) the National Study
of African American Life, with 6,000
participants; and 3) the National Study of Latino and Asian
Americans, with 5,000 participants. Each of these,
like the NCS-R, will provide information on
diagnosis, medications, disability/impairment, and
service use, drawing from nationally based samples.
An international perspective on these findings is
also becoming available, as the study is part of
a global initiative on the epidemiology of mental
disorders in 28 countries, coordinated through
the World Health Organization.
For more information on the NCS-R, visit
http://www.nimh.nih.gov/healthinformation/ncs-r.cfm.
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