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Chapter 14
The Primary Care of Mental Disorders in the United States
Philip S. Wang, M.D., Dr. P.H.
Department of Health Care Policy, Harvard Medical School
Department of Psychiatry and Division of Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Women’s Hospital, Harvard Medical School
Michael Lane, M.S.
Department of Health Care Policy, Harvard Medical School
Mark Olfson, M.D., M.P.H.
Department of Psychiatry, Columbia University
Harold A. Pincus, M.D.
Department of Psychiatry, University of Pittsburgh
Thomas L. Schwenk, M.D.
Department of Family Medicine, University of Michigan
Kenneth B. Wells, M.D., M.P.H.
Department of Psychiatry and Biobehavioral Sciences, University of California
at Los Angeles
Ronald C. Kessler, Ph.D.
Department of Health Care Policy, Harvard Medical School
Summary
Although the general medical sector traditionally has played an important
role in the treatment of people with mental disorders, it has undergone dramatic
changes during the past decade. For this reason, up-to-date
information on the use of primary care for mental disorders in the United States
is urgently needed.
In this chapter, we provide data on the patterns and predictors of 12-month
mental health treatment in the general medical sector from the National Comorbidity
Survey Replication (NCS-R). The
NCS-R is a nationally representative
face-to-face
household survey of 9,282 English-speaking
respondents ages 18 and older carried out between February 2001 and April 2003.
Respondents were given a fully structured diagnostic interview, using the World
Health Organization (WHO) World Mental Health (WMH) Survey Initiative version
of the Composite International Diagnostic
Interview (WMH-CIDI). The proportions
of respondents with 12-month
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)
anxiety, mood, impulse control, and substance abuse disorders who received treatment
in the 12 months before the interview in the general medical sector were calculated.
These proportions of respondents were compared with the proportions using other
service sectors (specialty mental health, human services, and complementary-alternatives).
The number of visits made in the prior year and the proportion of patients who
received minimally adequate treatment were also assessed.
A larger proportion of respondents (9.3 percent), including those with (22.8
percent) and without (4.7 percent) 12-month DSM-IV disorders, received mental
health services in the general medical sector in the prior year than in any
other sector. However, the mean number of 12-month visits among those treated
in the general medical sector (2.6) was considerably lower than in any other
sector. Furthermore, only a third of treated cases in the general medical sector
received minimally adequate treatment; even employing our broadest definition,
this percentage was again lower than for cases treated in any other sector.
Among those treated in the health care system, receiving specifically primary
care for mental disorders was related to being older aged, female, less educated,
not married, and living in rural areas.
Although the use of primary care to treat mental disorders in the United States
has grown rapidly during the past decade, the intensity and adequacy of those
treatments remain poor. We provide possible explanations for these findings,
including the many structural and financial barriers primary care providers
now face. We close by suggesting some new perspectives and policy directions
that may be needed to improve the primary care of mental disorders in the United
States.
Background
The primary care sector traditionally has played an important role in the
treatment of people with mental disorders
in the United States. In the Epidemiologic Catchment Area (ECA) study conducted
in the 1980s, 12.7 percent of respondents with 12-month
DSM-III (American Psychiatric
Association, 1980) mental disorders received treatment in the general medical
sector in the year before interview—a proportion equal to those receiving
care in the mental health specialty sector (Regier et al., 1993). In the National
Comorbidity Survey (NCS) conducted in the 1990s, the proportion of respondents
with DSM-III-R
(American Psychiatric Association, 1987) disorders receiving treatment in the
general medical sector was 7.9 percent, a smaller proportion than those treated
in the specialty sector (12.4 percent), but not dramatically so (Kessler &
Wang, 1999).
Since then, there have been many important changes with potentially large
impacts on the primary care of mental disorders in the United States. The recent
Surgeon General’s Report (U.S. Department of Health and Human Services,
1999) and the President’s New Freedom Commission on Mental Health (2004)
have emphasized detection of mental disorders and use of evidence-based
treatments in general medical settings. Community campaigns promoting awareness,
screening, and help-seeking for
mental disorders largely in primary care have been launched (Hirschfeld et al.,
1997; Jacobs, 1995). The introduction of newer, more tolerable pharmacologic
treatments has made it easier for primary care providers to treat people with
mental disorders (Leucht, Pitschel-Walz,
Abraham, & Kissling, 1999; Olfson et al., 2002a; Schatzberg & Nemeroff,
2004). The era of managed care also has brought with it greater emphasis on
the delivery of mental health treatments in primary care settings (Sturm &
Klap, 1999; Weissman, Pettigrew, Sotsky, & Regier, 2000; Williams, 1998;
Williams et al., 1999). The increasing "medicalization" of mental
health care and direct-to-consumer
advertising of pharmacological treatments have further increased consumer demand
for general medical services (Relman, 1980; Rosenthal, Berndt, Donohue, Frank,
& Epstein, 2002).
Up-to-date
data are imperative to assess the impact of these changes and to identify the
role that the general medical sector now plays in caring for people with mental
disorders. Earlier research found that the recognition
of mental disorders in primary care was poor, with as many as half of active
cases not receiving correct diagnoses (Simon & Von Korff, 1995). Furthermore,
rates of treatment initiation and the quality of treatments for mental disorders
in primary care have been low, with only the minority of patients receiving
care that meets minimal quality standards (Wang, Berglund, & Kessler, 2000;
Wang, Demler, & Kessler, 2002; Wells, Schoenbaum, Unutzer, Lagomasino, &
Rubenstein, 1999; Young, Klap, Sherbourne, & Wells, 2001). Up-to-date
data on the intensity and adequacy of treatments received in primary care are
crucial to guide future policy initiatives in this area.
The goals of this chapter are to provide basic descriptive data on the primary
care of mental disorders from the NCS-R, conducted between 2001 and 2003 (Kessler
et al., in press a). We first identify the proportions of cases with 12-month
mental disorders who obtain any treatment in the general medical as well as
other service sectors. We also calculate the typical number of visits made and
the proportion receiving minimally adequate treatment for mental disorders in
primary care and compare these numbers to other service sectors. Finally, we
identify demographic correlates of seeking health care treatment for mental
disorders in the general medical sector.
Methods
Sample
The NCS-R is a nationally representative
face-to-face
household survey of respondents ages 18 and older in the coterminous United
States (Kessler et al., in press a; Kessler & Merikangas, in press). Interviews
were carried out between February 2001 and April 2003 on 9,282 respondents.
A core diagnostic assessment was administered to all respondents in Part I.
Part II contained assessments of risk factors, correlates, service use, and
additional disorders and was given to all Part I respondents with lifetime disorders
plus a probability subsample of other
respondents. Recruitment, consent, and field procedures used in the NCS-R
were approved by the Human Subjects Committees of both Harvard Medical School
and the University of Michigan. The overall NCS-R
response rate was 70.9 percent.
Measures
WHO WMH-CIDI Survey: Diagnostic assessments of 12-month mental
disorders were made using WHO’s WMH Survey Initiative version of the CIDI
(Kessler & Ustun, in press). The WMH-CIDI is a fully structured lay-administered
diagnostic interview that generates both ICD-10 (WHO, 1991) and DSM-IV (American
Psychiatric Association, 1994) diagnoses. Twelve-month disorders considered
here include mood (bipolar I and II disorders, major depressive disorder, and
dysthymia), anxiety (panic disorder, agoraphobia without panic, specific phobia,
social phobia, generalized anxiety disorder, obsessive-compulsive disorder,
post-traumatic stress disorder, and separation anxiety disorder), impulse-control
(intermittent explosive disorder), and substance disorders (alcohol and drug
abuse and dependence). Organic exclusions were employed with diagnostic hierarchy
rules (except for substance disorders for which abuse is defined with or without
dependence). The Structured Clinical Interview for DSM-IV (SCID) (First, Spitzer,
& Williams, 1995) was used to conduct blind clinical reappraisals (Kessler
et al., under review). These reappraisals showed generally good concordance
between WMH-CIDI lifetime diagnoses and the SCID for anxiety, mood, and substance
disorders (lifetime diagnoses of WMH-CIDI impulse-control disorders have not
been validated). Evaluation of WMH-CIDI 12-month diagnoses is currently ongoing.
Mental Health Service Use in the Year Prior to Interview: Initial
questions asked all Part II respondents whether they ever received treatment
for "problems with your emotions or nerves or your use of alcohol or drugs."
Respondent booklets were provided as visual recall aids and contained lists
of the types of treatment providers. Assessments included different types of
professionals, support groups, self-help groups, mental health crisis hotlines
(assumed to be visits with nonpsychiatrist mental health specialists), complementary
and alternative medicine (CAM) therapies, and use of treatment settings such
as hospitals and other facilities (each day of admission was assumed to include
a visit with a psychiatrist). Respondents were then asked followup questions
about their age at first and most recent contacts as well as the number and
duration of visits in the past 12 months.
Endorsements of 12-month service
use were classified into the following categories: psychiatrist; nonpsychiatrist
mental health specialist (psychologist or other nonpsychiatrist mental health
professional in any setting, social worker or counselor in a mental health specialty
setting, or use of a mental health hotline); general medical provider (primary
care doctor, other general medical doctor, nurse, or any other health professional
not previously mentioned); human services
professional (religious or spiritual advisor, or social worker or counselor
in any setting other than a specialty mental health setting); and CAM professional
(any other type of healer, such as chiropractor, participation in an internet
support group, or participation in a self-help
group). Psychiatrist and nonpsychiatrist specialist categories were combined
into a broader mental health specialty (MHS) category; MHS was also combined
with general medical (GM) into an even broader health care (HC) category. Human
Services (HS) and CAM providers were also combined into a Non-Health
Care (NHC) category.
Definitions of Minimally Adequate Treatment: We initially
created a broad definition of minimally adequate treatment to accommodate respondents
who began treatments shortly before the NCS-R
interview and therefore might not have had time to fulfill requirements, even
if they were in the process of receiving adequate treatment. Furthermore, this
broad definition of minimally adequate treatment was designed to accommodate
the possibility that respondents may have been receiving very brief treatments
that have been developed for certain disorders (Ballesteros, Duffy, Querejata,
Arino, & Gonzales-Pinto, 2004;
Ost, Ferebee, & Furmark, 1997). This broad definition of minimally adequate
treatment consisted of receiving ≥ two visits to an appropriate treatment sector
(i.e., one visit for presumptive evaluation/diagnosis and ≥ one visit for treatment)
or being in ongoing treatment at interview.
We also attempted to construct a narrower definition of minimally adequate
treatment based on available evidence-based
guidelines (Agency for Health Care Policy and Research, 1993; American Psychiatric
Association, 1998, 2000, 2002, 2004;
Lehman & Steinwachs, 1998). This consisted of receiving either pharmacotherapy
(≥ 2 months of an appropriate medication for the focal disorder plus ≥ four
visits to any type of medical doctor) or psychotherapy (≥ eight visits with
any health care or human services professional lasting an average of ≥ 30 minutes).
We required ≥ four physician visits for pharmacotherapy based on the fact that
≥ four visits for medication evaluation, initiation, and monitoring are generally
recommended during the acute and continuation phases of treatment in available
guidelines (Agency for Health Care Policy and Research, 1993; American Psychiatric
Association, 1998, 2000, 2002, 2004; Lehman & Steinwachs, 1998). Medications
considered appropriate for disorders included antidepressants for depressive
disorders; mood stabilizers or antipsychotics for bipolar disorders; antidepressants
or anxiolytics for anxiety disorders; antagonists or agonists (e.g., disulfiram,
naltrexone, or methodone) for alcohol and substance disorders; and any psychiatric
drug for impulse control disorders (Schatzberg & Nemeroff, 2004). We required
at least eight sessions for minimally adequate psychotherapy because clinical
trials demonstrating effectiveness have generally included ≥ eight psychotherapy
visits (Agency for Health Care Policy and Research, 1993; American Psychiatric
Association, 1998, 2000, 2002, 2004; Lehman & Steinwachs, 1998). Self-help
visits of any duration were counted as psychotherapy visits for alcohol and
substance disorders.
For respondents with comorbid disorders, treatment adequacy was defined separately
for each 12-month
disorder (i.e., a respondent with comorbid disorders could be classified as
receiving minimally adequate treatment for one disorder but not for another).
Predictor Variables: Demographic variables examined as potential predictors
of service use included co-hort (defined by age at interview and categorized
as 18–29, 30–44, 45–59, 60+); gender; race-ethnicity (Non-Hispanic
White, Non-Hispanic Black, Hispanic, Other); completed years of education (0–11,
12, 13–15, and 16+); marital status (married-cohabitating, previously
married, never married); family income in relation to the Federal poverty line
(categorized as low [≤ 1.5 times the poverty line], low average [1.5+
to 3 times], high-average [3+ to 6 times], and high [6+ times]; urbanicity defined
according to 2000 Census (U.S. Census Bureau, 2000) definitions (large and smaller
Metropolitan Areas; Central Cities, Suburbs, and Adjacent Areas; and Rural Areas);
and health insurance coverage (including private, public, or military sources).
Analyses: NCS-R data were first weighted to adjust for differences
in probabilities of selection, differential nonresponse, residual differences
between the sample and the U.S. population, and over-sampling in the Part II
sample (Kessler et al., under review).
We examined basic patterns of service use by calculating the percentages receiving
treatment in any and particular service sectors, the frequency of visits among
those in treatment, and probabilities of treatments meeting criteria for our
broad and narrow definitions of minimal adequacy. We examined the sociodemographic
predictors of receiving any 12-month treatment in the total sample and treatment
in the general medical sector among those receiving any health care treatment
using logistic regression (Hosmer & Lemeshow, 1989) analysis.
The Taylor series method as implemented in SUDAAN (2002) was used to estimate
standard errors. Statistical significance was evaluated using two-sided
design-based tests and the .05
level of significance. Wald χ2 tests were
used to test significance in logistic regression analyses and were based on
coefficient variance–covariance matrices adjusted for design effects using
the Taylor series method.
Results
Twelve-Month Use of
the General Medical Sector for Mental Health Services: In the total
sample, 9.3 percent of respondents received mental health services in the general
medical sector in the prior year, a percentage
higher than for any other sector. The proportions using the general medical
sector were also greater than for any other sector when the sample was broken
down into those with 12-month
mental disorders (22.8 percent) and without (4.7 percent). Among cases with
specific 12-month DSM-IV
disorders, the proportions receiving
treatment in the general medical sector were highest for those with panic (43.7
percent), dysthymia (39.6 percent), bipolar (33.1 percent), or major depressive
disorder (32.5 percent) and lowest for specific phobia (21.2 percent), alcohol
dependence (19.3 percent), alcohol abuse (16.4 percent), or intermittent explosive
disorder (12.6 percent) (table 14.1).
Mean Number of Visits in the General Medical Sector: The mean
number of 12-month visits (table
14.2) among those receiving any treatment in the general medical sector
was 2.6 and was considerably lower than the mean visits made in any other sector.
The mean visits among those treated in the general medical sector were higher
among those with disorders (2.9) than without (2.0), but not dramatically so.
The mean visits in the general medical services sector among cases with specific
disorders was highest for dysthymia (4.2) or panic disorder (4.1) and lowest
for intermittent explosive disorder (2.2).
The median numbers of visits (not shown, but available upon request) were consistently
lower than the means. For example, the median among patients receiving any treatment
in the general medical sector was 1.6. The median visits to the general medical
sector was 1.7 among patients with a 12-month
disorder and 1.1 among those without. This greater magnitude of means than medians
implies that a relatively small number of patients treated in the general medical
sector receive a disproportionately higher share of all visits.
Proportions receiving minimally adequate treatment in the general medical
sector: Table 14.3 shows the proportions
of treated cases receiving minimally adequate treatment using our initial broad
definition (i.e., receiving ≥ two visits to an appropriate sector or being in
ongoing treatment at the time of interview). The percentage of treated cases
receiving minimally adequate treatment in the general medical sector was only
33.2 percent; lower than in any other sector. Among cases with specific 12-month
DSM-IV disorders, the proportions
receiving minimally adequate treatment in the general medical sector were highest
for those with separation anxiety disorder (63.7 percent), agoraphobia (60.6
percent), or dysthymia (46.1 percent) and lowest for drug abuse/dependence (18.0
percent), obsessive compulsive disorder (20.1 percent), or alcohol abuse/dependence
(30.9 percent).
In analyses employing our narrower definition of minimally adequate treatment,
only 12.7 percent of cases treated in the general medical sector qualified as
receiving such care (not shown, but available upon request). Again, this proportion
was lower than that observed for any other sector.
Predictors of Receiving Treatment in the General Medical Sector:
After controlling for the presence of all individual 12-month
mental disorders, the odds of receiving any 12-month
mental health treatment are significantly
related to being younger than age 60, female, non-Hispanic
White, not having low-average
family income, being previously married, and not living in a rural area (not
shown, but available upon request). Among those who received any treatment,
treatment in one of the health care sectors is significantly related to not
being in the age range 18–29, not being non-Hispanic
Black, living in rural areas, and having health insurance.
Among those who received health care treatment, receiving treatment specifically
in the general medical sector was significantly related to being older aged,
female, less educated, not married, and living in a rural area (see table
14.4).
Discussion
These results indicate that there has been a rapid rise in the use of primary
care to treat mental disorders in the United States. Currently 22.8 percent
of those with disorders receive treatment in the general medical sector, nearly
triple the percentage observed in the NCS a decade ago (Kessler et al., 1999).
Among treated cases, well over half now receive some form of primary care for
their mental disorders—a proportion larger than for any other sector.
General medical sector treatment is now the sole form of health care used by
over one-third of cases accessing
the health care system. This dramatically increased use of primary care for
mental disorders in the NCS-R
confirms the findings of other recent surveys. For example, the Healthcare for
Communities (HCC) survey found that people with mental health needs are largely
treated by primary care providers and that this trend increased over the period
from 1997–8 to 2000–1 (Mechanic & Bilder, 2004). The National
Medical Expenditure Survey and Medical Expenditure Panel Survey also found an
increase in the use of physicians relative to mental health specialists during
the 1990s (Olfson et al., 2002a).
Several factors could help explain this increased use of primary care for mental
disorders. Employing primary care physicians as "gatekeepers" has
been one way that managed health plans have shifted mental health contacts to
the general medical sector. While discontent has been growing over restricted
access to specialists, formal gatekeeping continues to cover nearly 40 percent
of patients, and higher cost alternatives allowing patients to self-refer to
specialists remain poorly subscribed (Forrest, 2003; Forrest et al., 2001; Kaiser
Family Foundation and Health Research Education Trust, 2000). Other developments,
such as improved recognition of how mental disorders present and the design
of primary care screening tools to detect mental disorders, have made it easier
to deliver mental health care in general medical settings (Kessler & Wang,
1999; Kroenke, 2003; Simon, Von Korff, Piccinelli, Fullerton, & Ormell,
1999; Spitzer, Kroenke, & Williams, 1999). Pharmacologic treatments with
improved safety profiles have made it easier for primary care providers to treat
mental disorders, and direct-to-consumer advertising has spurred patient demand
for such treatments (Gilbody, Wilson, & Watt, 2004; Leucht et al., 1999;
Olfson et al., 2002a; Schatzberg & Nemeroff, 2004). There has also been
a growing tendency for some primary care physicians to deliver psychotherapies
themselves (Gallo et al., 2002; Hegel, Dietrich, Seville, & Jordan, 2004;
Olfson, Marcus, Druss, & Pincus, 2002b).
While use of the general medical sector for mental health treatments clearly
has grown, the intensity and quality of those treatments remain shallow and
uneven. Cases treated in primary care received fewer visits in the prior year
than those treated in any other sector. Even using our broadest definition of
adequacy, only one-third of cases seen in the general medical sector received
minimally adequate care—again, a proportion lower than for any other sector.
These findings are consistent with earlier as well as more recent evidence.
In the ECA study, respondents with mental disorders treated in the general medical
sector received substantially fewer visits than those treated in specialty sectors
(Narrow, Regier, Rae, Manderscheid, & Locke, 1993). Other studies conducted
throughout the 1990s consistently found that only a minority of cases in primary
care receive treatments that meet minimal standards for adequacy (Wang et al.,
2000, 2002; Wells et al., 1999; Young et al., 2001). However, it is important
to keep in mind that the quality of care received in mental health specialty
settings was only moderately better in absolute terms, both in this study and
others (Blanco, Laje, Olfson, Marcus, & Pincus, 2002; Simon, Von Korff,
Rutter, & Peterson, 2001).
What explains the lower intensity and quality of mental health treatments in
primary care? One possibility is that primary care patients with mental disorders,
who typically present with somatic symptoms, may not believe that they have
a mental disorder or need treatment, leading to lower compliance with recommended
treatment regimens (Dietrich, Oxman, & Williams, 2003a; Kroenke, 2003; Mojtabai,
Ofson, & Mechanic, 2002; Simon et al., 1999). Patients seeking help from
general medical physicians have a less serious profile of disorders than those
treated in other sectors (Kessler et al., 1999; Olfson & Pincus, 1996),
which presumably impedes their unequivocal acceptance of physician formulations.
Primary care patients also have been found to have less psychiatric comorbidity
than patients seeking mental health specialty care (Kessler et al., 1999; Mojtabai
et al., 2002). This lower severity could influence not only patient adherence,
but also physician behavior, a possibility that is consistent with evidence
that severity is related to treatment intensity (Mojtabai et al., 2002; Wells
et al., 1999). However, some investigators have found only modest differences
in severity or impairment between primary care and specialty samples (Simon
et al., 2001), and others have found that the presence of even worrisome symptoms,
such as suicidal ideation, does not lead to more intensive treatment in primary
care (Wells et al., 1999). These latter findings suggest that higher quality
treatments are as necessary and beneficial in primary care as in mental health
specialty populations.
Some earlier studies have found that the ability of primary care physicians
to correctly diagnose and treat mental disorders was lower than that of mental
health specialists (Katon, Von Korff, Lin, Bush, & Ormel, 1992a; Simon &
Von Korff, 1995; Simon, Von Korff, Wagner, & Barlow, 1993; Wells et al.,
1989), and such findings have led to numerous educational and other training
initiatives (Hirschfeld et al., 1997). Some recent data suggest that general
medical physicians’ confidence in their abilities to treat mental disorders
remains low despite additional didactic training (Dietrich et al., 2003b). Other
data suggest that primary care physicians have improved rates of recognizing
and treating mental disorders (Carney, Dietrich, Eliassen, Owen, & Badger,
1999), and in some treatment contexts primary care physicians and mental health
specialists have similar levels of guideline-concordant care (Dietrich et al.,
2003a; Simon et al., 2001).
Structural and financial barriers almost certainly play key roles in undermining
the intensity and quality of mental health care in the general medical sector.
Primary care physicians must deal with all of a patient’s health needs,
including the considerable general medical comorbidity that afflicts primary
care populations (Starfield et al., 2003). This situation frequently leads to
"competing demands" on physicians’ limited time and resources
(Jaen, Stange, & Nutting, 1994; Klinkman, 1997). Another important structural
barrier primary care physicians face is the paucity of available mental health
referrals (Trude & Stoddard, 2003). Capitated or bundled payments for primary
care physicians and capitated referral systems, used in many managed care organizations,
discourage maintenance treatment and referral to mental health specialists (Frank,
Huskamp, & Pincus, 2003). Behavioral
health carve-outs, now covering
50 to 70 percent of insured populations, can further erode general medical physicians’
financial incentives to adequately treat mental disorders as well as fragment
and disorganize mental health care (Findlay, 1999; Frank et al., 2003; Frank
& McGuire, 1998).
Use of the general medical sector varies across individual mental disorders.
Panic disorder, which frequently presents with somatic symptoms, may prompt
general medical attention; on the other hand, specific phobia, which often involves
lower levels of subjective distress, may be less likely to prompt patients to
seek primary care treatment (Brunello et al., 2001; Katerndahl & Realini,
1995; Katon, Von Korff, & Lin, 1992b; Leaf et al., 1985; Solomon & Gordon,
1988). Externalizing disorders (e.g., substance disorders and intermittent explosive
disorder) may also be associated with lower perceived needs for treatment, as
well as tendencies for patients and providers to view these problems as social
or criminal rather than medical in nature (Kaskutas, Weisner, & Caetano,
1997; Mojtabai et al., 2002). Also, effective primary care treatments are just
emerging, which may be another cause of lower treatment rates for impulse-control
disorders (Fava, 1997; Olvera, 2002).
The sociodemographic predictors of general medical sector use are generally
consistent with prior research. The greater use of primary care for mental disorders
by older people may be due to the stigma of mental disorders in the elderly,
the unacceptability of mental health specialty treatments, and high rates of
general medical care use for medical problems in the age group (Fischer, Wei,
Solberg, Rush, & Heinrich, 2003; Klap, Unroe, & Unutzer, 2003; Leaf
et al., 1985). The fact that female patients are more likely than male patients
to use the general medical sector may be due to primary care physicians’
greater willingness to treat women, while referring men to mental health specialists
(Kessler, 1986; Shapiro et al., 1984). Because we adjusted for income, the inverse
relationship between education and general medical sector use is not just due
to education serving as a proxy for greater financial resources to pay for mental
health specialty services; instead, these results could reflect the greater
emphasis on knowledge and cognitive processes in many specialty psychotherapies
(Wells, Manning, Duan, Newhouse, & Ware, 1986). The diminished use of primary
care among those separated, widowed, or divorced may indicate that those experiencing
relationship loss or strife often seek out counseling (Leaf et al., 1985). Greater
use of primary care for mental health needs in rural areas may reflect the structural
reality that mental health specialty resources are scarce outside of urban and
suburban areas (Rost, Fortney, Fischer, & Smith, 2002).
There are, of course, several sets of potential limitations to keep in mind
when interpreting these results. The WMH-CIDI did not assess all DSM-IV disorders.
The most important consequence of this frame exclusion is that some respondents
classified as not having a mental disorder may actually have met criteria for
a DSM-IV disorder that was not assessed. People who were homeless or institutionalized
were also excluded. However, the results reported here should still apply to
a large majority of the population because the homeless and institutionalized
make up a small percentage of the U.S. population.
People with mental disorders may also have had higher survey refusal rates
(i.e., systematic survey nonresponse)
or rates of recall failure, conscious nonreporting, and errors in the diagnostic
evaluation (i.e., systematic nonreporting) than those without disorders. A likely
consequence of such errors is that unmet needs for treatment have been underestimated
(Allgulander, 1989; Cannell, Marquis, & Laurent, 1977; Eaton, Anthony, Tepper,
& Dryman, 1992; Kessler et al., in press a; Kessler et al., under review;
Turner et al., 1998).
Another potential limitation concerns the validity of self-reports
of treatment use. Some investigators have found that self-reports
of mental health service use overestimate treatment records (Rhodes & Fung
2004; Rhodes, Lin, & Mustard, 2002). Questions designed to measure a subject’s
commitment to the survey (i.e., commitment probes) and exclusion of the <
1 percent of respondents who failed to endorse that they would think carefully
and answer honestly were employed in the NCS-R
to minimize such inaccuracies. However, to the extent that they occurred, they
are likely to have caused us to underestimate unmet needs for treatment.
The validity of our definitions of minimally adequate treatment is another potential
limitation. For example, brief treatments have been described for certain phobias
(Ost et al., 1997) and alcohol disorders (Ballesteros et al., 2004). Furthermore,
those diagnosed shortly before interview may not have had enough time to meet
our criteria for minimally adequate treatment. However, our broader definition
(≥ two visits to an appropriate sector or being in ongoing treatment at the
time of interview) should have taken these possibilities into account.
Finally, we did not attempt to determine needs for treatment based on the seriousness
of disorders, as doing so was beyond the scope of this initial descriptive report.
It therefore remains possible that respondents with untreated or inadequately
treated disorders are disproportionately made up of mild or self-limiting cases.
Despite these potential limitations, the results reveal that improvements in
the primary care of mental disorders are warranted. Even though there has been
a large increase in the proportion of people with mental disorders receiving
treatment, particularly in the general medical sector, many active cases still
go untreated. Additional outreach efforts are clearly still needed to promote
recognition of disorders and timely initiation of treatments. Concentrating
these efforts in general medical settings seems indicated given, that they are
increasingly the de facto portals of entry into the service delivery system
for most people with mental health needs. Expanding awareness programs and use
of tools to screen for mental disorders in primary care practices may be effective
ways to achieve these goals (Hirschfeld et al., 1997; Jacobs, 1995; Spitzer
et al., 1999).
Efforts to improve the quality of treatments are also sorely needed in light
of the widespread low intensity and inadequacy of existing primary care for
mental disorders. Simply introducing treatment guidelines and other simple educational
approaches have not proven to be successful. However, a range of multifaceted
primary care interventions that include elements of clinician and patient education,
care management, and greater integration of primary and specialty care have
proven to be effective and in some cases cost-effective (Gilbody, Whitty, Grimshaw,
& Thomas, 2003; Katon et al., 1995; Katon, Roy-Byrne, Russo, & Cowley,
2002; Wells et al., 2000). Establishing performance standards, such as the Substance
Abuse and Mental Health Services Administration’s (SAMHSA’s) Center
for Mental Health Services Consumer-Oriented Mental Health Report Card or the
new National Committee for Quality Assurance standards, could further help enhance
the quality of primary care treatments and monitor the impact of future primary
care interventions (National Committee for Quality Assurance, 1997; Substance
Abuse and Mental Health Services Administration, 1996).
Beyond developing outreach and quality improvement initiatives, the longer
term task of achieving sustainable improvement in the primary care of mental
disorders remains. Primary care providers continue to face daunting financial
and structural barriers to delivering quality mental health care. These same
financial and structural barriers also deter the uptake of even effective model
approaches in primary care (Frank et al., 2003; Klinkman, 1997; Pincus, Hough,
Houtsinger, Rollman, & Frank, 2003; Williams, 1998; Williams et al., 1999).
Widespread dissemination of quality improvement programs may ultimately depend
on removing financial disincentives and redesigning current systems of care
(Frank et al., 2003; Williams et al., 1999). The Robert Wood Johnson Depression
in Primary Care Program is one ongoing initiative that seeks to align primary
care providers’ incentives to promote sustainable evidence-based
practice (Pincus et al., 2003). Finally, employer and governmental purchasers
currently hesitate to pay for even proven interventions because they lack metrics
for assessing return on investment (Wang, Simon, & Kessler, 2003). The National
Institute of Mental Health (NIMH)-sponsored
Work Outcomes Research and Cost-Effectiveness
Study (WORCS) is an ongoing initiative that will calculate returns on investment
to purchasers for investing in enhanced care of mental disorders (Wang et al.,
2003).
New Perspectives and Directions
Taken together, the results described above and in related studies lead to what
might be considered the fourth major stage in the development of an effective
and efficient approach to the care of mental illness. The first stage was characterized
by describing the volume of patients treated by the "hidden mental health
sector" and by characterizing the extent to which these services were
disorganized, inefficient, uncontrolled, and poorly reimbursed.
The second stage was characterized by the first of two very different approaches
to remedying these deficiencies. The
first approach was based on brute force or the "retail approach"
to educational interventions to improve what was assumed to be a knowledge and
skill deficiency in primary care physicians. This approach was taken so that
mental health care could be controlled by, and to a considerable extent limited
to, primary care physicians through gatekeeping and other means of limiting
access to specialty mental health providers. While promoted by many health care
plans as a way to "strengthen" the primary care physician’s
role in comprehensive health care, it
was viewed by most primary care physicians as a crude cost-containment
mechanism to limit services that many employers and payers perceived to have
relatively little value by. Despite a wide range of creative, intensive, and
theoretically sound approaches to education and professional development, including
studies based on intense, multifaceted educational interventions involving both
didactic and active experiences and case-based
exercises, outcome studies showed that the detection, accurate diagnosis, and
effective treatment of depression and other mental illnesses improved little.
Knowledge was a necessary but not sufficient condition to improve mental health
care in the primary care setting.
Attempts to restrict most mental health care to the primary care setting occurred
during the same period as the expansion of mental health "carve-outs."
These carve-outs required all
mental health care to be provided in mental health care settings, usually without
adequate or sometimes any communication with the patient’s pri-ary
care physician. Mental health carve-outs
were an effective approach for patients who actively sought specialty services.
However, this organizational structure did not well serve the large portion
of the primary care population who could not, would not, or did not seek such
care. Most important, capturing and confining all mental
health care in a single system, often organized through commercial contracts
with outside provider organizations,
limited care through restricted formularies and limits on the availability of
outpatient counseling and inpatient admission. Both the carving out and confinement
of services to a single provider group and the restrictions on access to services
stood in distinct contrast to the relatively open access to therapies and providers
for most other chronic medical conditions. The net effect of this approach was
to restrict access to mental health care for a large portion of the population
who resisted being carved out, as well as to limit mental health services to
those who actively sought such care.
The third phase of this evolution was the design and evaluation of stratified
approaches to allocating care based on severity and treatment response. In these
models, psychiatrists are available to primary care physicians for direct (to
patient) or indirect (to primary care physician) consultation; case managers
follow patients closely and provide support, counseling, and education; and
patients receive a variety of additional support and monitoring services. These
approaches show significant benefit in adherence to medication regimens, treatment
response, and functional outcomes but are unsustainable financially. Almost
universally, these studies showed positive results while receiving support and
funding but left no enduring legacy when the research funding ended. Care reverted
to baseline levels.
The net effect of these three phases was to raise the consciousness of primary
care physicians and their patients regarding the importance and legitimacy of
effective treatment for mental illness. This experience also demonstrated new
approaches that led to markedly improved outcomes, but without providing new
resources or access to the incremental reimbursement necessary to support the
required intensity of care to achieve such outcomes. Little evidence
existed that a multifaceted, structured, and stratified approach to mental illness
care could be supported through usual practice revenues, or that most payers
were willing to make the necessary investment in such programs—despite
evidence of significant cost savings through reduced utilization of inappropriate
medical care, decreased attrition, decreased disability, improved performance,
and decreased absenteeism.
In combination with the data described above, these lessons lead naturally to
a fourth stage characterized by the following critical questions that are worthy
of attention by health services investigators, payers, employers, and health
policy experts.
1. To what degree is the considerable mental illness care provided in the non-mental
health care sector inevitable, because of a shortage of mental health care professionals
(particularly psychiatrists), or desirable?
2. What financial structures and payer mechanisms are necessary to support
the case management, stratified care, and structured consultation–liaison
relationships that have been shown to be feasible and effective but unsustainable
in the current health care system?
3. How could the treatment of mental illness be rationally allocated between
the service sectors to result in higher levels of treatment to remission and
more effective care of psychiatric comorbidity?
4. Is it possible for the treatment of mental illnesses to become a model for
how a highly prevalent and expensive
set of persistent conditions could be addressed by primary care and specialty
sectors in a "both/and," rather than an "either/or"
paradigm?
The current model of chronic disease care, and particularly the care of patients
with multiple chronic diseases, is fragmented,
inefficient, ineffective, and expensive. Health policy experts and national
organizations have made several calls for new models for the population-based
care of chronic disease. The new models would be required to allocate resources
rationally; stratify care according to severity and complexity; and ensure
that medical care information is structured, organized, and shared in sophisticated
ways among a team of providers, including both primary care physicians and specialty
consultants. Such calls have, in general, not yet led to substantial changes.
The care of mental illness could become the paradigm for such a systemic change.
ACKNOWLEDGEMENTS
The National Comorbidity Survey Replication (NCS-R)
is supported by NIMH (U01-MH60220)
with supplemental support from the National
Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services
Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044708),
and the John W. Alden Trust. Collaborating NCS-R
investigators include Ronald C. Kessler (Principal Investigator, Harvard
Medical School), Kathleen Merikangas (Co-Principal
Investigator, NIMH), James Anthony (Michigan State University), William Eaton
(The Johns Hopkins University), Meyer Glantz (NIDA), Doreen Koretz (Harvard
University), Jane McLeod (Indiana University),
Mark Olfson (New York State Psychiatric Institute, College of Physicians
and Surgeons of Columbia University), Harold Pincus (University of Pittsburgh),
Greg Simon (Group Health Cooperative), Michael Von Korff (Group Health Cooperative),
Philip Wang (Harvard Medical School), Kenneth Wells (UCLA), Elaine Wethington
(Cornell University), and Hans-Ulrich
Wittchen (Max Planck Institute of Psychiatry; Technical University of Dresden).
The views and opinions expressed in this chapter are those of the authors and
should not be construed to represent the views of any of the sponsoring organizations,
agencies, or U.S. Government. A complete
list of NCS publications and the full text of all NCS-R
instruments can be found at http://www.hcp.med.harvard.edu/ncs.
Send correspondence to ncs@hcp.med.harvard.edu.
The NCS-R is carried out in conjunction
with the World Health Organization World Mental Health (WMH) Survey Initiative.
We thank the staff of the WMH Data Collection and Data Analysis Coordination
Centres for assistance with instrumentation, fieldwork, and consultation on
data analysis. These activities were supported by the National Institute of
Mental Health (R01-MH070884),
the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the
U.S. Public Health Service (R13-MH066849,
R01-MH069864, and R01-DA016558),
the Fogarty International Center (FIRCA R01-TW006481),
the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil
Pharmaceutical, Inc., GlaxoSmithKline, and Bristol-Myers
Squibb. A complete list of WMH publications
can be found at http://www.hcp.med.harvard.edu/wmh/.
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