Mental Health Service Use Up, but Many Still Go Untreated

Batya Swift Yasgur, MA, LSW

December 03, 2018

Use of outpatient mental health services has increased among US adults, but many with serious psychological distress still go untreated, new research shows.

Investigators analyzed 10-year data from almost 140,000 US adults and found that serious psychological distress declined between 2004-2005 and 2014-2015. Significant declines occurred in all age groups, in all major racial/ethnic groups, and in both sexes.

The percentage of adults who received outpatient mental health services increased during that period. There was a higher proportional increase in those who were more distressed, and there was a higher absolute increase in those with less serious or no psychological distress.

"Despite recent progress in increasing the likelihood that US adults with serious psychological distress receive mental health treatment, nearly a third still receive no treatment," lead author Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, told Medscape Medical News.

"Because most of these adults make regular primary care visits, there are opportunities through mental health screening to increase detection of their distress and either treat or refer them for mental health care," he said.

The study was published online November 28 in JAMA Psychiatry.

Do Services Align With Need?

"Over the past several years, there have been indications of an increase in the annual percentage of US adults who receive outpatient mental health care," the authors write.

However, "concern exists over the extent to which use of mental health services aligns with need for treatment," they add.

"In earlier research, we observed that there had been a recent decrease in the percentage of US children and adolescents with severe mental impairments, alongside rising rates of mental health treatment," said Olfson.

"These findings led us to wonder whether similar trends were occurring among US adults," he said.

To examine recent trends in psychological distress and their relationship with use of outpatient mental health services, the researchers analyzed data from the household component of the Medical Expenditure Panel Surveys for the periods 2004-2005, 2009-2010, and 2014-2015. The surveys were conducted by the Agency for Healthcare Research and Quality.

The sample analyzed consisted of 139,862 participants (51.67% women; 67.11% white; overall mean age, 46.41 years; SE, 0.14 years).

Psychological distress was measured using the Kessler 6 (K-6) scale, which included questions concerning the frequency of sadness, nervousness, restlessness, hopelessness, feeling that everything is an effort, and sense of worthlessness during the past 30 days.

Outpatient mental health service was defined by the patient's having an outpatient visit in which a mental disorder was diagnosed; use of psychotherapy; or use of psychotropic medications.

Age of the adults was stratified as younger, middle-aged, or older (18 - 39 years, 40 - 50 years, and ≥60 years, respectively).

Respondents also reported sex and race/ethnicity (white or nonwhite). In some analyses, race/ethnicity was further defined as white, African American, Hispanic, or other.

Less Distress, More Service Use

Through the first 5 years, the percentage of adults with serious psychological distress remained fairly constant (from 4.82% in 2004-2005 to 4.93% in 2009-2010).

By contrast, during the total 10-year period (from 2004-2005 to 2014-2015), significant declines in the odds of serious psychological distress were observed for participants in each group. There was an overall decline in psychological distress from 4.82% in 2004-2005 to 3.71% in 2014-2015.

Significant declines were observed among young, middle-aged, and older adults (from 3.94% to 3.07%; from 5.52% to 4.36%; and from 5.24% to 3.79%, respectively).

Both men and women showed significant declines (from 3.94% to 3.09% for men and from 5.64% to 4.29% for women).

Similar findings were obtained for all major racial/ethnic groups (white, 4.52% to 3.82%; African American, 5.12% to 3.64%; Hispanic, 6.03% to 3.55%; and other, 5.22% to 3.26%).

The estimated annual number of US adults who received any outpatient mental health care increased from 41.82 million (95% confidence interval [CI], 38.97 - 44) in 2004-2005 to 56.00 million (95% CI, 52.77 - 59.20) in 2014-2015.

This absolute increase was largely attributable to the increase in treatment of adults with less serious or no psychological distress, from 35.17 million (95% CI, 32.64 - 37.71) in 2004-2005 to 47.69 million (95% CI, 44.80 - 50.61) in 2014-2015.

Overall, the percentage of adults who received any outpatient mental health service increased from 19.08% in 2004-2005 to 23.00% in 2014-2015 (adjusted odds ratio [OR], 1.25; 95% CI, 1.17 - 1.34).

The researchers found that although the proportionate increase in use of outpatient mental health services for adults with serious psychological distress (54.17% to 68.40%) was larger than that for adults with less serious or no psychological distress (17.26% to 21.08%), the absolute increase in outpatient mental health service use was "almost completely the result of growth in outpatient mental health service use by individuals with less serious or no psychological distress."

Similarly, among adults who used any outpatient mental health service, the percentage with serious psychological distress declined; however, the decline was proportionately less than the decline among adults who did not use outpatient mental health services.

Welcome Trend

There was little change in the use of psychotherapy among all adults during all the three periods.

However, when examining particular groups, the researchers found that psychotherapy use increased among adults with serious psychological distress but not among adults with less serious or no psychological distress.

During each period, psychotherapy was used significantly more frequently by younger than by older adults, by women more frequently than by men, and by white adults more frequently than nonwhite adults.

Significant increases in use of psychotropic medications (antidepressants, anxiolytics/sedatives, antipsychotics, mood stabilizers, and stimulants) were observed among adults both above and below the serious psychological distress threshold.

However, compared with participants with less serious or no psychological distress, those with serious psychological distress experienced a greater relative increase in use of any psychotropic medication and anxiolytics/sedatives.

Within each period, the odds of using any psychotropic medication were over twice as great for middle-aged and older adults than for younger adults; for women than for men; and for white than for nonwhite adults. A similar pattern was found for antidepressants.

Notably, the odds of anxiolytic/sedative use were markedly higher for older adults than for younger adults in all three periods.

Significant relative increases in any outpatient mental health service use by general medical professionals occurred in all demographic groups and in those with as well as those without severe psychological distress. There was a greater increase in men than in women.

The relative increase in treatment by psychiatrists was greater for older adults than for younger adults or middle-aged adults and increased for both sexes as well as for white and nonwhite people.

For individuals with serious psychological distress, there was a greater relative increase in treatment by other mental health professionals.

The authors suggest potential contributors to the increase in outpatient mental health care. These include improved public attitudes toward seeking mental health treatment, changes in clinical diagnostic practices, US Food and Drug Administration approval of new psychotropic medications, and increases in psychotropic prescribing by primary care physicians.

One limitation of the study is that the K-6 is "not a diagnostic measure"; it represents only depression and anxiety symptoms and omits more severe disorders, the authors state.

"Against a backdrop of rising national rates of suicide and drug overdose, we were surprised to find that there has been a decline in the percentage of US adults with serious psychological distress," said Olfson.

"This welcome trend cuts against what has been a common impression of increasing psychological distress driving a national increase in 'death of despair,' " he said.

Important Snapshot

Commenting on the study for Medscape Medical News, John W. Newcomer, MD, president and chief executive officer, South Florida Behavioral Health Network, and adjunct professor of psychiatry, Washington Univeristy School of Medicine, St. Louis, Missouri, who was not involved with the study, called it "another very useful step in wrapping our head around understanding the delivery of mental health services in the US and an important snapshot or perspective on how those services are being delivered and to whom."

Newcomer echoed the author's caveat that the K-6 is not a diagnostic tool or "direct proxy."

Moreover, "you can’t understand all the complex dynamics of the US mental health system from this one study," he said.

Nevertheless, the investigators made "great use of some of the available data out there" and did "very thoughtful analyses to try to advance our understanding.

"The good news in this story is that the numbers are going down in previously identified groups where individuals who would seem to very clearly have need and were not receiving services in the past and those receiving services is going up," he added.

"Although progress has been made, improvements are still needed in general medical settings in detecting and either treating or referring adults in need of mental health care," the authors conclude.

The Medical Expenditure Panel Surveys are sponsored by the Agency for Healthcare Research and Quality. Funding for this project was provided by a grant from the National Institutes of Health and the New York State Psychiatric Institute. Dr Olfson and Dr Newcomer have disclosed no relevant financial relationships. The other authors' disclosures are listed in the original article.

JAMA Psychiatry. Published online November 28, 2018. Abstract

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