of all lifetime cases of mental illness begin by age 14, and despite
effective treatments for the disorders, there are long delays between
the onset of symptoms and seeking treatment, according to the largest
survey ever of the nation’s mental health,published in the June
6 issue of the Archives of General Psychiatry.
These treatment delays—which can span decades—lead
to more severe and difficult-to-treat illnesses and to co-occurring
And, once people do get treatment, few receive care that meets “minimally
accepted standard” for mental health treatment, researchers
The landmark study, called the “National Comorbidity
Survey Replication,” was led by Harvard University, the National
Institute of Mental Health (NIMH) Intramural Research Program and
of Michigan. Based on interviews with 9,282 randomly selected American
adults, this survey is an expanded follow-up to the 1990 “National
Comorbidity Survey,” designed to measure the severity and prevalence
of mental illness, and the quality of treatment.
“There are many important messages from this study,” said
NIMH Director Thomas Insel, M.D. “But perhaps none as important
as the recognition that mental disorders are the chronic disorders
of young people in the U.S.”
In fact, anxiety disorders often begin in late childhood, mood disorders
in late adolescence and substance abuse in the early 20s, with three-quarters
of all lifetime cases beginning by age 24.
Treatment Delays Harm the Public Health
the two most alarming findings are the lag between the onset of an
illness and the start of treatment, and the effect of these delays
on the public health.
The median treatment delay for all disorders is about a decade, but
delays vary among different disorders. For example, the longest delays—20-23
years—are for social phobia and separation anxiety disorder.
Researchers found shorter delays in treatment among people with mood
a still much-prolonged six to eight years.
They also found that disorders that emerge in childhood are associated
with the longest delays in treatment,even though childhood disorders
more serious than those that strike later in life.
Researchers say children are less likely to receive timely treatment
because they rely on parents or other adults to recognize symptoms,
but adults often miss the signs unless they are extreme.The authors
also found long delays in treatment among minorities compared to non-Hispanic
pattern appears to be that the earlier in life the disorder
the slower an individual
is to seek therapy.”
These findings suggest a need for increased awareness
and outreach efforts—especially
considering the dangers associated with untreated disorders that strike
at a young age:school failure, teenage childbearing,unstable employment,
early marriage, and marital instability and violence.
According to the researchers, early treatment
is simpler and could prevent“enormous disability” later.
It also halts the development of co-occurring disorders, which are
to get under
control, especially as they accumulate.
“The pattern appears to be that the earlier in life the disorder
begins, the slower an individual is to seek therapy,” said Ronald
Kessler, Ph.D., the leader of the study and professor of health care
policy at Harvard Medical School. “It’s unfortunate that
those who most need treatment are the least likely to get it.”
Disorders Common in U.S.
The survey also found that mental disorders
overall are common in the United States—more than one-quarter
of the general population surveyed reported having symptoms within
the past year that would meet the criteria for a diagnosable mental
disorder. Researchers point out, however, that many of these cases
are mild or resolve themselves without treatment.
The “main burden of illness,” they said,falls on those
with severe disorders,which is about 6 percent of the population.
NIMH and its partners in the study define a “severe disorder” as
one that limits daily activities, or involves work disability, a suicide
attempt with“serious lethal intent,” or psychosis. Survey
respondents with severe disorders reported a mean of nearly three
months a year during which they could not perform normal daily activities.
Although eight out of 10 people who have a mental disorder will eventually
seek care, according to the survey, the episodes can increase in severity
and frequency, and grow resistant to treatment when left untreated
for extended periods.
Unfortunately, nearly half of those who have one
mental disorder have one or more additional disorders, the researchers
of each illness is “strongly” related to comorbidity—meaning
that the more disorders you have, the more severe each may be. This
striking finding supports a growing belief among some researchers
that the distinctions between professionally recognized diagnoses
fuzzier than originally believed.
Prevalence by Disorder
The survey was described in four papers and
focused on four major categories of mental illness: anxiety disorders,
disorders, impulse control disorders and substance abuse. Anxiety
disorders have the earliest onset and are also the most prevalent
class of disorders,
affecting nearly 30 percent of the population, closely
followed by impulse control disorders at about 25percent, mood disorders
at close to 21 percent and substance use at about 15percent.
However, the most prevalent lifetime disorders are
major depressive disorder at about 17 percent, followed by alcohol
abuse at 13 percent,
specific phobia at12.5 percent and social phobia at 12 percent.
In terms of severity, over a year-long period, 22 percent of all
reported cases were serious, more than one-third were moderate and
Researchers Recommend Early Intervention
The study overall illustrates
that our nation’s mental healthcare system is not keeping pace
with consumer needs. For example, over a one-year period, 60 percent
of those who have mental disorders received no treatment at all, the
study showed. And only 12.7 percent of the patients seen for mental
health problems by general medical providers—the most popular
choice for such care—received minimally adequate treatment.
The good news is that a higher proportion of people
who received mental health treatment increased to 17 percent—from 13 percent
a decade ago—which some attribute to public awareness campaigns,
direct-to-consumer advertising and a decrease in stigma.
The study’s lead researchers are also calling
for a focus on early interventions for children and prevention efforts
on halting the onset of multiple disorders.
“Widespread failure to disseminate proven interventions may,
in fact, explain why the large unmet need for treatment of mental
disorders persists in the U.S. despite earlier efforts to address
this problem," said
Researchers also see a need for increased outreach
screening programs to detect early onset of mental disorders," a
recommendation made by Kathleen Merikangas, a lead NIMH collaborator
in the study.
Similar studies are being performed in 28 other countries, as part
of a global initiative on examining the prevalence of mental disorders.