Two noteworthy limitations of this study are that severity was assessed indirectly in 1990–2 using imputation and treatment adequacy was not assessed. The strong relationship of imputed values to direct measures of severity in NCS-R and use of the multiple imputation method to adjust for the increase in error variance when computing significance tests minimize concerns about the first limitation. The second limitation is more concerning because research shows that many mental patients receive inadequate treatment.18
Adequacy of treatment could not be studied because too little information about processes of care was included in the earlier survey.
With these limitations in mind, the study documented five important results. First, no change occurred in prevalence or severity of mental disorders between 1990–2 and 2001–3. Two explanations consistent with this result are that prevalence would have been higher in the early 2000's than the early 1990's were it not for increased treatment; and that increased treatment was ineffective in causing a decrease in disorders. Consistent with the first possibility, the economic recession of the early 2000's began shortly before and deepened throughout the NCS-R field period, while the 9/11 attacks occurred in the middle of the field period. Mental disorders might have increased in the absence of increased treatment. However, more evidence is consistent with the second explanation. Studies show that most treatment for mental disorders falls below minimum quality standards.18
In addition, this treatment is typically of short duration, which means it would influence episode duration more than 12-month prevalence. Finally, increased treatment was provided largely in the GM sector to patients without NCS-R/DSM-IV disorders. Controlled treatment trials find no evidence that pharmacotherapy significantly improves such mild cases, making it unlikely that it could prevent a significant secular increase in disorder prevalence.
Second, a substantial increase occurred between 1990–2 and 2001–3 in the proportion of the population treated for emotional problems, even though the majority of people with disorders still received no treatment. The increased treatment could have been due to: aggressive direct-to-consumer marketing of new psychotropic medications;19
development of new community programs to promote awareness, screening, and help-seeking for mental disorders;20
expansion of primary care, managed care, and behavioral “carve-out” systems of mental health services;21
and new legislation and policies to reduce barriers to service use.22
Increased access presumably played an independent role.23
Insurance coverage expanded throughout the decade, while consumer cost sharing declined.
Third, increased treatment varied across sectors, leading to a composition shift in treatment, the most notable shift being a 150% increase in treatment in the GM sector. Despite hope that mental disorders would be treated more efficiently because of this shift, data show that many patients in GM treatment for emotional problems fail to complete the clinical assessment, delivery of treatment, and appropriate ongoing monitoring consistent with accepted standards of care.18
In addition, a high proportion of patients continue to receive treatments of uncertain benefit in the HS and CAM sectors.
Fourth, the increase in treatment was unrelated to socio-demographic correlates. As a result, increased treatment did not reduce socio-demographic inequalities found in the baseline NCS.24
Indeed, these inequalities increased in absolute terms. For example, although Non-Hispanic Blacks were only 50% as likely to receive PSY treatment as Non-Hispanic Whites with the same disorder severity in both surveys, the fact that PSY treatment increased by more than 100% means that this consistent difference resulted in the absolute Black-White treatment gap increasing by more than 100%.
Fifth, although a small positive association was found in both surveys between severity and treatment, severity did not interact with time in predicting treatment. This means that the proportional increase in treatment was the same for all levels of severity. The positive association between severity and treatment has previously been interpreted as evidence of rationality in allocation of treatment resources.24
However, the fact that roughly half of patients do not meet criteria for any DSM disorder assessed in surveys has led to controversy regarding the relationship between severity and treatment need.25, 26
Some commentators argue that treatment resources should be focused on serious cases.27
Others argue that cost-effectiveness might be as high treating mild cases28
or treating sub-threshold syndromes to prevent onset of future serious disorders.29
No comparative cost-effectiveness data exist to adjudicate between these contending views.
These results suggest two directions for future research and policy analysis. First, as most people with a mental disorder receive no treatment, efforts are needed to increase access and demand for treatment. The persistence of low treatment among traditionally underserved groups calls for special initiatives.30
The Surgeon General's report on under-treatment among racial-ethnic minorities1
and the NIMH initiative on under-treatment among men31
may provide useful models and should be evaluated. Programs to expand treatment resources in targeted locations could also be of value,32
as could initiatives such as legislation to encourage mental health service use among vulnerable elderly patients.22
Second, efforts are needed to evaluate the effectiveness of widely used treatments for which no effectiveness data exist and to increase use of evidence-based treatments. The expansion of disease management programs, treatment quality assurance programs, and “report cards” are important steps in this direction. Substantial barriers continue to exist, though, including competing clinical demands and distorted treatment incentives.33, 34
Initiatives aimed at overcoming these barriers are underway.35, 36
Future trend surveys need to include data on treatment processes, like those in the NCS-R, to allow changes in treatment quality to be tracked.