The results reported herein show that most people who use services for mental health or substance use problems in the United States have either a DSM
diagnosis or some other indicator of possible need for treatment. These findings extend those of previous studies in showing that a substantial percentage of service users did not have any of the 12-month DSM-IV
/CIDI diagnoses assessed in the survey4,13-15
despite the fact that a much wider range of conditions was considered herein than in earlier studies. However, when we focused on number of visits, we found that the nearly two-thirds of mental health service users who had a 12-month diagnosis accounted for approximately three-quarters of all professional visits for mental health or substance use problems. These results may help reduce concerns based on the findings of previous epidemiologic surveys that a high proportion of services are provided to patients who do not have a DSM
We also found that patients with lifetime but not 12-month diagnoses made up most other 12-month service users in the NCS-R. In this subsample of respondents, those with recent episodes were significantly more likely than others to be undergoing 12-month treatment, suggesting that they may be receiving time-limited treatment for recent episodes. Use of services among other patients with lifetime disorders may reflect the growing awareness that maintenance treatment is important for relapse prevention in people with a history of serious conditions.32-34
The fact that indicators of lifetime severity (number of diagnoses and lifetime history of hospitalization) were significant predictors of 12-month treatment is consistent with this hypothesis. This pattern is consistent with earlier NCS-R findings that allocation of services is significantly associated with burden of illness in patients with 12-month diagnoses.15,17,18
To the extent that maintenance treatment is taking place, asymptomatic patients with lifetime disorders in 12-month treatment may be treatment success stories. The comparatively high proportion of people with lifetime bipolar disorder in 12-month treatment despite not having a 12-month manic-hypomanic or depressive episode is an especially important case in point given the literature suggesting the value of maintenance therapy in this population.33,35
The fact that asymptomatic people with lifetime diagnoses had fewer visits than those with more symptoms or risk factors further suggests an underlying rationality in resource allocation among stable patients receiving maintenance treatment.
The finding that a meaningful proportion of services is provided to patients who do not meet either 12-month or lifetime criteria for any of the DSM-IV
disorders assessed in the NCS-R raises a more complex set of clinical and policy concerns. More than three-fourths of these patients had a subthreshold 12-month condition, reported a serious 12-month stressor, or had a history of hospitalization. Subthreshold syndromes are currently less well defined than threshold diagnoses, and relatively little is known about the risks and benefits of treating these conditions.36,37
Nonetheless, particularly in the presence of serious psychosocial stressors, arguments have been made that treatment of subthreshold syndromes can have value not only in reducing present distress and suffering but in preventing the future onset of syndromal disorders.38-40
The fact that in this subsample a dose-response relationship exists between number of indicators of potential need and service use suggests that treatment decisions are being made based on these types of considerations. More generally, our findings support the notion that need for care may be more appropriately thought of as a continuum than as a categorical construct.
Only a small proportion (8.0%) of service users did not have any of the indicators of need considered herein. For a wide range of medical interventions, it is commonly necessary to have some false-positive rate of treatment. For example, a review of the appendectomy literature found an inverse relationship between the perforation rate and the surgeon's false-positive rate, leading the authors to recommend that a 23% error rate (removal of a normal appendix) would be appropriate.41
For mental disorders, public health efforts such as social marketing and antistigma campaigns may simultaneously increase the rate of care in persons with and without disorders.42
Thus, some level of overtreatment may be an acceptable, and even desirable, consequence of efforts to reduce the problem of undertreatment of mental disorders.
Although service users without potential indicators of need reported similar reasons for using services as other mental health service users, they were much less likely than other patients to receive their care in the formal health care system and much more likely to be treated in the human services sector. This means that these presumably low-need patients are not contributing importantly to formal mental health expenditures, nor do they divert a substantial proportion of professional resources away from patients with diagnosable disorders. They account for only 1.9% to 2.4% of all visits to psychiatrists and other mental health professionals and 3.7% of all visits to general medical professionals for mental health or substance use problems. Note that 44.8% of these patients who used CAM services reported that prayer was the main service provided. This finding is consistent with previous research demonstrating the common use of prayer43
and clergy visits44
in the United States for problems in daily life.
These results should be interpreted with the following 2 limitations in mind. First, the CIDI does not provide a fully comprehensive assessment of all DSM-IV
disorders, nor is it completely accurate in the diagnoses it assesses, as it is somewhat conservative relative to the SCID. As a result, some of the respondents classified as not having had a 12-month disorder actually had one. Second, the study relied on self-reported measures of service use. Because reporting bias for mental health services seems to be greatest in persons with high levels of distress,45
such bias may be less of a concern for the population of primary interest in the present study (ie, patients with low evidence of need for treatment).
Although the study's findings should provide some reassurance regarding the magnitude of overtreatment of mental health and substance use problems in the United States, there is still much work to be done to ensure that mental health resources are used effectively and efficiently.45
Overuse can be a problem not only for persons without need who receive services but also for individuals with evidence of need who receive poor-quality services. From an economic perspective, poor quality of care represents wasted resources.46,47
The present study suggests that efforts to reduce waste need to shift from whether the wrong persons are receiving mental health care to ensuring that those who do receive care receive the right services, in the right manner, and at the right time.