Three sets of limitations should be kept in mind. First, although the methods, instruments, and sector classifications were kept largely the same between the NCS and NCS-R, the internal validity of responses could have been affected by even subtle differences in surveys, non-response, and non-reporting. For example, mental disorders were assessed differently and imputation was employed to ensure comparable estimation of prevalences over time. Accuracy of these imputations is supported by strong associations between imputed and direct assessments in the NCS-R.
Second, we cannot be certain whether those using sector profiles actually obtained any treatment, particular modalities, or adequate care. Our crude lower bound estimates suggest at least 10–15% of those using services fail to receive any active treatment. Among those using profiles capable of delivering combined psychotherapy plus pharmacotherapy, perhaps the minority actually obtain these modalities. Even those receiving pharmacotherapies and psychotherapies often fail to obtain regimens that meet minimal thresholds for adequacy (
18,
29). As a consequence, the actual number of patients that receive evidence-based pharmacotherapies and psychotherapies is likely to be much smaller than those with the potential to do so based on their sector profile use.
Finally, the external validity of these results may be limited because the sampling frame excluded people in institutions as well as the homeless and does not span all diagnostic categories. However such restricted sampling frames have been shown to exclude only a small proportion of mentally ill people and clinical reappraisal interviews have found that a vast majority of serious cases are detected by the NCS-R interview (
21).
With these potential limitations in mind, this study sheds light on both the complexity of the US mental health care delivery system as well as important shifts in the combinations of service sector utilization. General medicine without psychiatrists or other mental health professionals experienced the largest growth over the past decade and is now the most common profile. This increased use of general medical providers without specialists may be due to the fact that primary care physicians now act as “gatekeepers” for nearly one-half of patients (
30). Provision of mental health care in general medical settings has also been improved through greater understanding of how mental disorders present and design of primary care screening tools (
31,
32). Development and heavy promotion of new antidepressants and other psychotropic medications with improved safety profiles have further spurred care of mental disorders exclusively in general medical settings (
8,
9). There has also been a growing tendency for some primary care physicians to deliver psychotherapies themselves (
33).
Two aspects of this expanded use of general medical without specialty sectors warrant concern. One is that it has occurred equally for people with severe as well as less severe disorders. This is worrisome in light of growing evidence favoring combined psychotherapy and pharmacotherapy for patients with serious disorders (
10,
11). In addition, general medical care without specialty use may result in lower treatment intensity and adequacy than in specialty care (
29,
34).
Psychiatry is now the second most common profile and also one experiencing growth during the last decade. On one hand, this may seem surprising, given both cutbacks in spending for specialty care as well as warnings by psychiatrists that managed care and gatekeeping would lead to diminished use of their services (
32). This increase may reflect similar factors to those responsible for greater use of non-psychiatrist physicians, including diminished stigma, greater recognition of needs for mental health treatment, and greater availability and demand for pharmacotherapies (
5,
6,
35).
However, it is disconcerting that the temporal increase in psychiatrist use has not particularly benefited patients with serious conditions. The psychiatrist profile is one of the two examined in which combined modality treatment could have been received. As mentioned above, evidence has been growing that dual modality treatments are especially beneficial to those with more serious disorders (
10,
11). Primary care with non-psychiatrist mental health professionals was the other profile from which combined modality treatment could have been received. Unfortunately, it was used only modestly and did not increase between surveys. The fact that it, like psychiatry, was not more likely to be used by severe patients raises further questions over whether dual modality treatments are being optimally allocated.
Mental health care without treatment from physicians, representing possible use of psychotherapy alone, had been the most popular profile in the NCS but declined significantly in the past decade. This finding is consistent with a significant decrease in psychotherapy visits during the 1990s (
5,
33). It could reflect new restrictions on the number of psychotherapy sessions, increased patient cost-sharing, and reduced provider reimbursements for psychotherapy visits imposed by many payers (
36). It could also reflect changes in the popularity of therapeutic modalities, particularly patients’ growing preferences for psychotropic medications (
5).
The decreasing use of human services without health care sectors, may be part of a longer term decline in use of the clergy for mental health care (
37). Recent cut-backs in funding and programs in social services agencies may also be contributing to the declining use of this profile (
36). Exclusive use of complementary-alternative medicine also decreased dramatically, perhaps in response to accumulating evidence that these treatments may lack efficacy or pose safety problems (
14,
15).
Younger cohorts’ greater use of profiles capable of delivering psychotropic medications (PSY, GM without PSY or OMH) could reflect the particular popularity and successful promotion of these agents to younger people (
5,
9). By contrast older cohorts’ reduced use of profiles employing exclusively psychotherapy may reflect an unacceptability of this modality to the elderly (
38). Our observation that females receive less psychiatric services but more general medical services than males is consistent with earlier findings that primary care physicians are more willing to treat women but tend to refer men to specialists (
39). Racial and ethnic minorities’ greater reliance on exclusively human services may reflect their lower barriers to accessing religious leaders or social services agencies as well as prior experiences of prejudice and mistreatment within health care sectors (
16,
17,
40).
Non-married peoples’ greater use of profiles capable of delivering exclusively psychotherapy and reduced use of profiles capable of delivering exclusively pharmacotherapy may indicate that counseling is a preferred modality for relational difficulties (
41). Education’s positive relationship with profiles potentially employing psychotherapies and negative relationship with profiles potentially employing exclusively pharmacotherapies may reflect an importance placed on knowledge and cognitive processes in many psychotherapies (
42). Urbanicity’s positive association with exclusively using CAM and negative association with using human services without health care, may be due to structural realities that few CAM sources are found outside of urban areas while religious and social services may be the only resources available to rural residents (
43). The fact that use of human services without health care did not decline in rural as in urban areas may further indicate the reliance on religious leaders for mental health needs among rural residents.
These results clearly confirm key observations made by the President’s New Freedom Commission on Mental Health—that the US mental health care system remains fragmented and this complexity may be contributing to many Americans failing to receive the treatments they need (
2). While this analysis primarily focused on fragmentation of care
across sectors, the Commission also recognized the equally important fragmentation that can occur
within sectors due to the variety of competing clinical (e.g., mental health vs. general medical), social, and human service needs that many patients and their clinicians experience (
44).
Beyond documenting these realities, what can be done to address both types of fragmentation and help ensure that Americans with mental health needs receive effective care? In considering this difficult question, the Commission recommended overcoming obstacles posed by fragmentation by meeting six goals. The Commission’s first goal—increasing American’s awareness of their mental health needs—will almost certainly require renewed educational and awareness campaigns to promote the public’s recognition of disorders and sectors from which effective care can be received (
7). Another goal—early detection and treatment—would benefit from additional application of screening programs as well as timely referrals from non-health care to health care professionals (
31,
32,
45). The goal of increasing high-quality, consumer-oriented care will likely require expansion of treatment resources as well as demanding greater accountability for the outcomes resulting from the use of individual and profiles of sectors (
46). Eliminating current disparities in service use suggests that such initiatives and resources be focused on traditionally underserved groups, including racial and ethnic minority and rural communities (
47). Final goals call for increased uptake of best-practices that optimally employ generalists, specialists, and health technology. Such interventions may be especially needed to address
within sector fragmentation from competing clinical, social, and human service demands on clinicians’ limited time and resources. Several disease management models that employ allied health personnel and innovative decision-support systems to assist beleaguered clinicians, have already proven to be effective and may deserve wider dissemination (
48–
53). Recent legislation suggests the public may already be willing to pay for such programs to ensure that Americans receive effective care (
54). Parallel efforts to define return-on-investments are needed to generate analogous support among employer-purchasers for model programs that help transform the fragmented US mental health care delivery system (
37).
The publisher's final edited version of this article is available at 