May 7, 2003 BOSTON, MA -- The United States has a higher prevalence and lower treatment rate of serious mental illness than a number of other developed countries, according to a study published in a special edition on international health care in the May/June issue of the policy journal Health Affairs.
Treatment was also to be more strongly related to the ability to pay and less to need for care in the United States than the other countries. The study analyzed data from community surveys with more than 22,000 respondents in Canada, Chile, Germany, the Netherlands, and the United States. All these countries, except the United States, have universal health insurance.
Despite differences in treatment, researchers found remarkably similar high proportions of the population with mental disorders (17 to 29 percent), early age of onset (mostly in childhood through the early adult years), high rates of chronic mental illness, and high levels of adverse effects on jobs, marriages, and other aspects of life, said corresponding author Ronald Kessler, professor of health care policy at Harvard Medical School's Department of Health Care Policy.
"The consistency of these patterns across a wide variety of countries is striking," Kessler said. "Issue number one is that we can't wait as long as we do to get young people into treatment. Issue number two is that we have to do a better job of making sure patients are treated with the best available therapies once we manage to get them into treatment."
In all countries, young, poorly educated males with serious mental disorders are the least likely to receive treatment. The report suggests that school-based interventions in low-income school districts may help reach these young men to prevent progression from mild to more serious disorders.
Early intervention is uncommon but important, according to the report. "People with mild mental disorders, if left untreated, have a significant risk of future serious outcomes, such as attempted suicide, hospitalization, and work disability," the authors write.
"Most people with serious mental disorders have conditions that start in childhood or adolescence, but do not get treatment until adulthood," Kessler said. "The problems are usually quite serious by the time they go for professional help. In many cases, these people have dug themselves into quite a hole before getting treatment that would be difficult for even the most emotionally secure person to overcome, such as teen childbearing, school failure, violent relationships, and drug problems. We can't wait as long as we currently do to get these kids into treatment."
People with more serious disorders were more likely to receive treatment, but between one-third and two-thirds of people with serious disorders in the five countries reported receiving no treatment. No matter how mild or serious the mental disorder, people were more likely to receive treatment if they were older (except for Chile), educated, and female.
Kessler said he and his co-authors were also struck by the inadequate treatments in this country. "This involves both medical care that fails to conform with accepted treatment guidelines, such as a homeopathic dose of a psychopharmacological medication prescribed by a family doctor, or care in some other sector of the treatment system, such as self-help or religious counseling, that has not been shown to be effective in treatment clinically significant mental disorders."
The instrument used to assess mental illness in the surveys, the Composite International Diagnostic Interview (CIDI), was developed in 1990 by the World Health Organization (WHO). Kessler conducted one of the first major CIDI surveys, a nationally representative general population survey of the United States. When he became the chair of the WHO CIDI Advisory Committee in the late 1990s, Kessler established a data pooling project for cross-national comparative studies that led to this paper.
"The first generation of CIDI surveys focused on diagnoses, but did not have good information on severity, which can vary enormously," Kessler said. Severity estimates in this paper are rough. Kessler is one of two coprincipal investigators of an expanded survey, called the WHO World Mental Health survey initiative, which is being carried out in 28 countries with a combined sample size of more than 200,000 respondents. Analyses of the new surveys are beginning this year, Kessler said.
Harvard Medical School has more than 5,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 17 affiliated teaching hospitals and research institutes. Those HMS affiliated institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Hospital, Center for Blood Research, Children's Hospital, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, VA Boston Healthcare System.
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