Understanding Mental Health Treatment in Persons Without Mental Diagnoses: Results From the National Comorbidity Survey Replication

A 2006 report by the Insti-tute of Medicine1 described a gap in the quality of mental health care as great as or greater than that seen in the rest of the health care system. The report described a primary goal for quality improvement of reducing underuse and overuse of services. In documenting problems of underuse of services, the report cited studies indicating that only approximately half of persons with serious mental illnesses receive any treatment and that fewer than half of those treated receive care consistent with evidence-based guidelines.2-6 Government-sponsored quality improvement initiatives in the United States and abroad are seeking to address the problem of undertreatment of mental disorders through increased public awareness, systematic screening, and implementation of treatment guidelines.7-9 Overuse, defined as “when a health care service is provided under circumstances in which its potential for harm exceeds the possible benefit,”10(p1002) is an equally important but much less well understood concern in quality assessment. The classic example of overuse in medicine is the prescription of antibiotic agents for the common cold, which is a problem from a clinical perspective (exposure of patients to unnecessary risks) and a public health perspective (potential development of resistance).11 Similarly, overtreatment in mental health would present a clinical problem if it exposed patients to adverse effects or a public health problem if it diverted resources away from those with greater evidence of need.12 Although there has been little formal study of the problem of overuse in mental health services, community mental health surveys have consistently found that a substantial proportion of people in treatment for emotional problems do not meet the criteria for any of the 12-month diagnoses. Data from the 1980 Epidemiological Catchment Area Survey,13 the 1990−1992 National Comorbidity Survey,14,15 and the 2001−2003 National Comorbidity Survey Replication (NCS-R)4 all reported that approximately half of persons using mental health services during the year before interview did not meet the criteria for any of the DSM disorders assessed in the surveys. This pattern is not confined to the United States. Persons without diagnosed disorders make up most treated cases in mental health needs assessment surveys throughout the developed and developing worlds.16-18 This consistent finding has been interpreted as evidence of potential overuse, and recommendations have been made based on this conclusion to redistribute services from persons without diagnoses to those with more serious conditions.18 If overuse of services implies use of services in the absence of need, then evaluating this problem empirically requires carefully considering what we mean by the term need and what we include in the enumeration of mental health services. Clinical need is a complex concept, best conceptualized not as a single entity but as a series of overlapping constructs, including symptoms, disease burden, treatment effectiveness, and consumer perceptions.19-22 In assessing potential need it is critical to complement diagnosis with other measures of symptoms and psychosocial burden and with patients' explanations of why they sought care. In exploring the implications of use of services in the absence of diagnosis, it is also critical to understand where people are receiving their treatment. The types of mental health care that people obtain are heterogeneous, ranging from services delivered in specialty mental health settings, to those provided by general health professionals, to those obtained from nonprofessionals, such as clergy and self-help group facilitators.23 Whereas treatment in the formal health care system (either medical or mental health) contributes to rising health care costs, treatment delivered outside of those sectors has fewer implications for allocation of resources. This study examines the prevalence and characteristics of use of 12-month mental health services in people without 12-month mental disorders based on the most comprehensive survey ever conducted of the prevalence and correlates of mental disorders in the United States. Extending research from previous epidemiologic surveys, we seek to understand the extent to which patients who do not meet the 12-month criteria for any of the disorders assessed in the survey have other indicators of possible need. We examine the sectors where treatment is received, the number of visits made to each treatment sector, and patient self-reported reasons for seeking treatment.