Dr. Kessler Replies

To the Editor: The number of National Comorbidity Survey respondents with confirmed bipolar disorder (N=29) (1) was too small for powerful estimation of the survival curves used to study speed of initial treatment contact in our analyses. Bipolar disorder was consequently excluded from those analyses. However, consistent with the results reported by Ross J. Baldessarini, M.D., and colleagues, respondents in the small subsample of confirmed National Comorbidity Survey bipolar disorder patients reported an average delay of nearly 6 years before initial treatment contact. Although the difference is not statistically significant with such a small number of cases, it is interesting to note that the average delay in the National Comorbidity Survey is somewhat shorter than the one reported by Dr. Baldessarini and colleagues. This might be because they studied delay in obtaining appropriate treatment, whereas we studied delay before initial treatment contact. The former is greater than the latter, sometimes considerably so, because of errors of diagnosis and failure to make appropriate referrals. Given recent evidence that a high proportion of patients with mood disorders fail to receive appropriate treatment (2, 3), it is important to recognize that delay in receiving appropriate treatment has two separate components—delay on the part of the patient in making an initial treatment contact and delay on the part of the system in providing an appropriate treatment. Work to reduce both problems is needed if we are to increase the number of people with mental disorders who receive appropriate treatment.