The results from this study have important implications for patients, clinicians, and health services researchers. Though up to two thirds of those with depression and anxiety disorders received at least some mental health care in the year prior to the survey, only one fourth obtained treatments that could be considered consistent with evidence-based recommendations, even among those with the most serious and impairing mental illness. Such findings suggest that interventions are needed not only to improve mental health awareness and treatment seeking in the general population, but also to increase the extent to which the care received conforms with evidence-based recommendations.
Results from this study also provide some information that may help guide future efforts to improve the quality of mental health care. To properly develop and target quality improvement interventions, it is crucial to first understand the reasons why no treatment is obtained and why treatment that is obtained fails to conform with evidence-based recommendations. We began this process by identifying factors associated with receiving no mental health care; these included having less-severe mental illness, having fewer comorbid physical illnesses, and lacking insurance coverage for mental health visits. Other investigators have also found that those with less-severe mental illness receive less care and have suggested that this may be due to less actual or perceived need for treatment.18,19,21,22,27,28
Those requiring treatments for comorbid conditions may be more willing or have more opportunities to receive treatment for their mental disorders29
; another intriguing possible explanation is that patients or providers require a “legitimate” physical illness before treating psychiatric symptoms.30
The relation between insurance coverage and receiving care suggests that financial barriers are significant impediments to receiving any mental health care.
In the subsample of respondents who received treatment, we also identified predictors of receiving treatment that are inconsistent with evidence-based recommendations. Some factors, such as being black or lacking insurance coverage for mental health visits, were predictors of nonconcordant treatment in both the general medical sector and the mental health specialty sector. However, having less-severe mental illness and fewer comorbid physical illnesses were predictive of receiving nonconcordant treatment only in the general medical sector; conversely, being male was predictive of receiving nonconcordant treatment only in the mental health specialty sector.
It is important to consider possible explanations and implications of these findings. African Americans have been observed in other studies to receive inferior care for both physical and mental illnesses.18,31,32
In many prior studies, it was not possible to identify the degree to which the inadequate treatment received by African Americans was due to their failure to seek help or lack of access to the health care system, or the degree to which they had access but ultimately received care that was deficient. In this study, we disaggregated the process of receiving guideline-concordant treatment and found that being black was not a significant predictor of whether one successfully obtained any mental health care or care in particular sectors of the health care system; a recent study also found that in the 1990s, African Americans had become as likely as whites to receive any mental health care.33
However, in our study we found that among those who successfully obtained some mental health care in either the general medical or mental health specialty sectors, blacks were much less likely to receive treatment that conformed with evidence-based recommendations. The degree to which this finding may be due to a greater likelihood for African Americans to prematurely leave treatment, a treatment bias on the part of providers, or other reasons should receive further study.
Our observation that insurance coverage was significantly related to receiving guideline-consistent care in both the general medical and mental health specialty sectors is relevant in the debate over the need for parity between coverage for physical disorders and mental disorders. Our results indicate that insurance coverage for mental illness must be broad, or both access to and the standards of mental health care will suffer.
It is not clear why those with less-severe mental illness or fewer comorbid physical illnesses were more likely to receive guideline-inconsistent care in the general medical sector but not the mental health specialty sector. It may reflect the fact that in their new roles as gatekeepers, primary care providers must triage patients, deciding whose symptoms do and whose do not warrant more-intensive treatment. Primary care physicians may also increasingly find themselves experiencing a climate of competing demands, in which their limited time and resources need to be spent attending to general medical rather than mental illnesses.34,35
Alternatively, these results may indicate the continued need to improve recognition and treatment of mental illness by general medical doctors, particularly among patients with moderate or atypical symptoms.27–30
The reasons for the greater likelihood of women receiving guideline-concordant treatment from mental health specialists are also unclear. Earlier research has suggested that women have a greater ability to translate nonspecific feelings of distress into conscious recognition that they have an emotional problem and therefore are more likely to seek, accept, and continue in treatment.36,37
Results from this study should be interpreted with the following 3 sets of limitations in mind. First, although deviation from recommendations in evidence-based treatment guidelines9–11
is likely to represent inadequate care in the majority of cases, in some circumstances deviation could represent appropriate treatment. In addition, some subjects who were diagnosed shortly (e.g., 1–2 months) before being surveyed may have only begun treatment and not had adequate time to fulfill the required number of visits. To the extent that either of these occurred, we may have underestimated the extent of guideline-concordant treatment. Conversely, we may have counted visits in which the respondent's mental health problem was not addressed toward the required number of visits, causing us to overestimate the degree of concordance of the treatment. Also, because of the nonrandom way in which treatments had been used in the study population, we could not investigate whether receiving concordant care was associated with improved health outcomes.
A second set of limitations includes the cross-sectional nature of this study. Due to this it is difficult to conclude that factors associated with receiving particular treatments are related causally (e.g., although lack of insurance coverage appears to cause a greater likelihood of nonconcordant treatment, it is possible that poorly treated mental illness leads individuals to lose insurance coverage).
Third, we only examined the influence of some patient and health care system factors on the type of mental health care received, and did not have the ability to investigate other important factors such as those related to providers. In the absence of such information, it is difficult to determine the degree to which nonconcordant treatments are due to clinicians (e.g., not initiating treatments or not prescribing them for adequate durations or intensity) or to patients (e.g., not adhering to treatments). Finally, although it is possible to compare results from the MIDUS study with results from earlier surveys, it is difficult to determine the degree to which methodologic differences between studies versus true temporal changes underlie observed differences in mental health care.
Despite these potential limitations, the results of this study provide evidence of the continuing challenges faced by those with mental illness and those who deliver or seek to improve mental health care in the United States. Despite the availability of an increasing number of effective treatments, many of those with common mental disorders fail to receive at least some form of mental health care. In addition, there are the enormous challenges of improving the quality of treatments and adherence to treatments, tasks made more difficult by limited health care resources. Future studies will need to focus on increasing our understanding of modifiable factors contributing to substandard treatment of mental illnesses, including clarifying why race, gender, insurance status, severity of mental illness, and comorbid physical illness are related to the quantity and guideline concordance of the mental health care received. Such information will be crucial for designing and targeting cost-effective interventions that improve treatment access, treatment quality, and ultimately the health outcomes of those with mental illnesses.