Changing Profiles of Service Sectors Used for Mental Health Care in the United States

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 the NCS Replication, the internal validity of responses could have been affected by even subtle differences in surveys, nonresponse, and nonreporting. For example, mental disorders were assessed differently, and imputation was employed to ensure comparable estimation of prevalences over time. The accuracy of these imputations is supported by strong associations between imputed and direct assessments in the NCS Replication.

Second, we cannot be certain whether those using profiles actually obtained any treatment, particular modalities, or adequate care. Our crude lower-boundary estimates suggested that 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 obtains these modalities. Even those receiving pharmacotherapies and psychotherapies often fail to receive regimens that meet minimal thresholds for adequacy (18, 29) . As a consequence, the actual number of patients who receive evidence-based pharmacotherapies and psychotherapies is likely to be much smaller than those with the potential to do so based on their 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 did 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 Replication interview (21) .

With these potential limitations in mind, this study sheds light on both the complexity of the U.S. mental health care delivery system as well as important shifts in the combinations of service sectors that individuals use. The general medical only profile 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 because primary care physicians now act as “gatekeepers” for nearly one-half of patients (30) . The provision of mental health care in general medical settings has also been improved through greater understanding of how mental disorders present and the design of primary care screening tools (31, 32) . The 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 the general medical only profile 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) .

The psychiatry profile is now the second most commonly used 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 factors similar to those responsible for greater use of nonpsychiatrist physicians, including diminished stigma, greater recognition of the need for mental health treatment, and greater availability and demand for pharmacotherapies (5, 6, 35) .

However, it is disconcerting that the temporal increase in use of the psychiatrist profile has not particularly benefited patients with serious conditions. The psychiatrist profile is one of two examined in which combined modality treatment could have been received. As mentioned, evidence has been growing that dual-modality treatments are especially beneficial to those with more serious disorders (10, 11) . The general medical with mental health specialty profile was the other one 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 the psychiatry profile, was not more likely to be used by severely ill patients raises further questions regarding whether dual-modality treatments are being optimally allocated.

The other mental health specialty only profile, 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 third-party payers (36) . It could also reflect changes in the popularity of therapeutic modalities, particularly patients’ growing preferences for psychotropic medications (5) .

Decreasing use of the human services only profile may be part of a longer-term decline in the use of the clergy for mental health care (37) . Recent cutbacks in funding and programs in social services agencies may also be contributing to the declining use of this profile (36) . Use of the complementary/alternative medicine only profile 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 (the psychiatrist profile or the general medical only profile) could reflect the particular popularity and successful promotion of these agents to younger people (5, 9) . By contrast, the older cohorts’ reduced use of profiles employing psychotherapy exclusively may reflect an unacceptability of this modality to the elderly (38) . Our observation that women receive fewer psychiatric services but more general medical services for mental health care than men 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 the human services only profile may reflect their ease of access to religious leaders or social services agencies, as well as prior experiences of prejudice and mistreatment within profiles involving health care sectors (16, 17, 40) .

Nonmarried peoples’ greater use of profiles capable of delivering exclusively psychotherapy and their reduced use of profiles capable of delivering pharmacotherapy exclusively may indicate that counseling is a preferred modality for relational difficulties (41) . Education’s positive relationship with profiles potentially employing psychotherapies and negative relationships with profiles potentially employing pharmacotherapies exclusively may reflect an importance placed on knowledge and cognitive processes in many psychotherapies (42) . Urbanicity’s positive association with the complementary/alternative medicine only profile and its negative association with the human services only profile may be due to structural realities that few complementary/alternative medicine sources are found outside urban areas, whereas religious and social services may be the only resources available to rural residents (43) . The fact that use of the human services without health care only profile 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 U.S. mental health care system remains fragmented and that this complexity may be contributing to many Americans failing to receive the treatments they need (2) . Although this analysis primarily focused on fragmentation of care across sectors, the commission also recognized the equally important fragmentation that can occur within sectors because of the variety of competing clinical (e.g., mental health versus 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 profiles for 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 profiles involving exclusively non-health-care-providers to those involving 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 different profiles (46) . Eliminating current disparities in service use suggests that such initiatives and resources should be focused on traditionally underserved groups, including racial and ethnic minorities and rural communities (47) . Final goals call for increased undertaking 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 – 52) . Recent legislation suggests that the public may already be willing to pay for such programs to ensure that Americans receive effective care (53) . Parallel efforts to define return on investments are needed to generate analogous support among employer purchasers for model programs that help transform the fragmented U.S. mental health care delivery system (37) .

Collaborating investigators include Ronald C. Kessler (principal investigator, Harvard Medical School), Kathleen Merikangas (co-principal investigator, NIMH), James Anthony (Michigan State University), William Eaton (Johns Hopkins University), Meyer Glantz (National Institute on Drug Abuse), Doreen Koretz (Harvard University), Jane McLeod (Indiana University), Mark Olfson (Columbia University College of Physicians and Surgeons), Harold Pincus (University of Pittsburgh), Greg Simon and Michael Von Korff (Group Health Cooperative), Philip Wang (Harvard Medical School), Kenneth Wells (UCLA), Elaine Wethington (Cornell University), and Hans-Ulrich Wittchen (Max Planck Institute of Psychiatry).

Received Nov. 11, 2005; revision received Feb. 27, 2006; accepted March 14, 2006. From the Department of Health Care Policy, Harvard Medical School; the Department of Psychiatry and the Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School; the New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York; Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh; and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles. Address correspondence and reprint requests to Dr. Wang, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115; [email protected] (e-mail).The National Comorbidity Survey (NCS) was supported by NIMH grants (R01-MH-46376, R01-MH-49098, and RO1-MH-52861), with supplemental support from the National Institute on Drug Abuse (NIDA) (through a supplement to grant MH-46376) and the W.T. Grant Foundation (90135190). The NCS Replication is supported by an NIMH grant (U01-MH-60220), with supplemental support from the NIDA, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (grant 044708), and the John W. Alden Trust. The NCS Replication is carried out in conjunction with the World Health Organization’s World Mental Health Survey Initiative. World Mental Health Data Collection and Data Analysis Coordination Centres activities were supported by the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the U.S. Public Health Service (grants R13-MH-066849, R01-MH-069864, and R01-DA-016558), the Pan American Health Organization, Eli Lilly and Company, and GlaxoSmithKline.The authors thank Kathleen Merikangas and Bedirhan Ustun for comments on early drafts and the staff of the World Mental Health Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis.