Barriers to mental health treatment: results from the National Comorbidity Survey Replication.
TL;DR: Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.
Abstract: BackgroundThe aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population.MethodRespondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment.ResultsLow perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions.ConclusionsLow perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.
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TL;DR: Stigma has a small- to moderate-sized negative effect on help-seeking and Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma.
Abstract: BACKGROUND: Individuals often avoid or delay seeking professional help for mental health problems. Stigma may be a key deterrent to help-seeking but this has not been reviewed systematically. Our systematic review addressed the overarching question: What is the impact of mental health-related stigma on help-seeking for mental health problems? Subquestions were: (a) What is the size and direction of any association between stigma and help-seeking? (b) To what extent is stigma identified as a barrier to help-seeking? (c) What processes underlie the relationship between stigma and help-seeking? (d) Are there population groups for which stigma disproportionately deters help-seeking? METHOD: Five electronic databases were searched from 1980 to 2011 and references of reviews checked. A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative syntheses and subgroup analyses, was conducted. RESULTS: The review identified 144 studies with 90,189 participants meeting inclusion criteria. The median association between stigma and help-seeking was d = - 0.27, with internalized and treatment stigma being most often associated with reduced help-seeking. Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly reported stigma barrier. A detailed conceptual model was derived that describes the processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma. CONCLUSIONS: Stigma has a small- to moderate-sized negative effect on help-seeking. Review findings can be used to help inform the design of interventions to increase help-seeking.
1,938 citations
Cites background from "Barriers to mental health treatment..."
...A major national population study concluded that by far the largest treatment barriers was wanting to handle the problem on one’s own, followed by low perceived need for care (Mojtabai et al. 2011)....
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TL;DR: The complex elements of stigma are reviewed in order to understand its impact on participating in care and public policy considerations in seeking to tackle stigma in orderto improve treatment engagement are summarized.
Abstract: Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.
938 citations
Cites background or methods from "Barriers to mental health treatment..."
...Findings from the National Comorbidity Survey Replication showed that about 45% of respondents with a disorder who did not seek treatment reported low perceived need (Mojtabai et al., 2011)....
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...…Comorbidity Survey, in which participants who perceived a need for mental health services and were unable to obtain them reported structural hurdles including financial barriers (15.3%), lack of availability of services (12.8%), and problems in transportation to care (5.7%; Mojtabai et al., 2011)....
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Book•
01 Nov 2009
TL;DR: It is tested whether significant differences in mental illness exist in a matched sample of Mental illness and the criminal justice system.
Abstract: We test whether significant differences in mental illness exist in a matched sample of Mental illness and the criminal justice system. In T. L. Scheid T. N. Brown (Eds.), A handbook for the study of mental health: Social contexts, theories. Find 9780521567633 A Handbook for the Study of Mental Health : Social Contexts, Theories, and Systems by Horwitz et al at over 30 bookstores. Buy, rent. A review of mental health problems in fathers following the birth of a child. for the study of mental health:Social contexts, theories, and systems (2nd ed., pp.
842 citations
University of São Paulo1, St George's Hospital2, University of Otago3, Universidad Autónoma Metropolitana4, Stony Brook University5, Katholieke Universiteit Leuven6, Utrecht University7, University of Ibadan8, Peking University9, Harvard University10, Paris Descartes University11, Mental Health Services12, Leipzig University13, Ulster University14, Pontifical Xavierian University15, All India Institute of Medical Sciences16, University of Cape Town17, Universidade Federal do Espírito Santo18, Universidade Nova de Lisboa19
TL;DR: Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide.
Abstract: The WHO WMH Survey Initiative is supported by the National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864 and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481). The Sao Paulo Megacity Mental Health Survey is supported by the State of Sao Paulo Research Foundation (FAPESP) Thematic Project Grant 03/00 204-3. The ESEMeD project is funded by the European Commission (Contracts QLG5-1999-01 042; SANCO 2 004 123 and EAHC20081308), the Piedmont Region (Italy), Fondo de Investigacion Sanitaria, Instituto de Salud Carlos III, Spain (FIS 00/0028), Ministerio de Ciencia y Tecnologia, Spain (SAF 2000-158-CE), Departament de Salut, Generalitat de Catalunya, Spain, Instituto de Salud Carlos III (CIBER CB06/02/0046, RETICS RD06/0011 REM-TAP). The World Mental Health Japan (WMHJ) Survey is supported by the Grant for Research on Psychiatric and Neurological Diseases and Mental Health (H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013) from the Japan Ministry of Health, Labor and Welfare. The Lebanese National Mental Health Survey (LEBANON) is supported by the National Institute of Health/Fogarty International Center (R03 TW006481- 01. The Mexican National Comorbidity Survey (MNCS) is supported by The National Institute of Psychiatry Ramon de la Fuente (INPRFMDIES 4280) and by the National Council on Science and Technology (CONACyT-G30544-H). The Ukraine Comorbid Mental Disorders during Periods of Social Disruption (CMDPSD) study was funded by the US National Institute of Mental Health (RO1-MH61905). The US National Comorbidity Survey Replication (NCS-R) is supported by the NIMH (U01-MH60220), the Robert Wood Johnson Foundation (RWJF; Grant044780)
766 citations
Cites background from "Barriers to mental health treatment..."
...As in previous surveys, we found that being female, being younger or middle-aged and having severe/ moderate disorders are associated with perceived need for treatment, and with reporting more structural barriers to treatment-seeking (Mojtabai et al. 2002; Cohen-Mansfield & Frank, 2008; Codony et al. 2009; Mojtabai et al. 2011)....
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...…that being female, being younger or middle-aged and having severe/ moderate disorders are associated with perceived need for treatment, and with reporting more structural barriers to treatment-seeking (Mojtabai et al. 2002; Cohen-Mansfield & Frank, 2008; Codony et al. 2009; Mojtabai et al. 2011)....
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TL;DR: An estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders is provided to provide a significant 3-fold preference for psychological treatment.
Abstract: OBJECTIVE Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.
550 citations
References
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TL;DR: Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups.
Abstract: Context Little is known about lifetime prevalence or age of onset of DSM-IV disorders. Objective To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older. Main Outcome Measures Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders. Results Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups. Conclusions About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.
17,213 citations
"Barriers to mental health treatment..." refers background or methods in this paper
...As described elsewhere (Kessler et al. 2005a), blind clinical re-interviews using the Structured Clinical Interview for DSM-IV (SCID) (First et al....
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...In Poverty in the United States : 2001....
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...Twelve-month use of mental health services in the United States : results from the National Comorbidity Survey Replication....
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...The NCS-R is a nationally representative household survey of respondents aged o18 years in the contiguous United States (Kessler et al. 2004, 2005a)....
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...In the context of these limitations, the data provide a broad overview of perceived barriers to initiation and continuation of mental health treatments in the United States....
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TL;DR: Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity, as shown in the recently completed US National Comorbidities Survey Replication.
Abstract: Background Little is known about the general population prevalence or severity of DSM-IV mental disorders. Objective To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Main Outcome Measures Twelve-month DSM-IV disorders. Results Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Conclusion Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
10,951 citations
"Barriers to mental health treatment..." refers background or methods in this paper
...In Poverty in the United States : 2001....
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...Twelve-month use of mental health services in the United States : results from the National Comorbidity Survey Replication....
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...As reported elsewhere (Kessler et al. 2005b), mean number of days in the past 12 months that respondents were completely unable to carry out their normal daily activities because of mental or substance use problems was 88....
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...The NCS-R is a nationally representative household survey of respondents aged o18 years in the contiguous United States (Kessler et al. 2004, 2005a)....
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...In the context of these limitations, the data provide a broad overview of perceived barriers to initiation and continuation of mental health treatments in the United States....
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TL;DR: An overview of the World Mental Health Survey Initiative version of the WHO Composite International Diagnostic Interview (CIDI) is presented and a discussion of the methodological research on which the development of the instrument was based is discussed.
Abstract: This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.
4,232 citations
"Barriers to mental health treatment..." refers methods in this paper
...As described elsewhere (Kessler et al. 2005a), blind clinical re-interviews using the Structured Clinical Interview for DSM-IV (SCID) (First et al. 2002) with a probability subsample of NCS-R respondents found generally good concordance between WMH-CIDI diagnoses and SCID diagnoses....
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...%) of the 1350 Part II NCS-R respondents who met criteria for at least one 12-month DSM-IV/CIDI disorder but did not use any 12-month services reported that they might have needed to see a professional for mental health problems....
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...DSM-IV diagnoses were based on version 3.0 of the Composite International Diagnostic Interview (CIDI) (Kessler & Üstün, 2004), a fully structured lay interview that generates diagnoses according to International Classification of Diseases, 10th Revision (WHO, 1992) and DSM-IV (APA, 1994) criteria....
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...The analyses were restricted to respondents with at least one 12-month CIDI/DSM-IV disorder....
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TL;DR: Most people with mental disorders in the United States remain either untreated or poorly treated, and interventions are needed to enhance treatment initiation and quality.
Abstract: Background Dramatic changes have occurred in mental health treatments during the past decade. Data on recent treatment patterns are needed to estimate the unmet need for services. Objective To provide data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey using a fully structured diagnostic interview, the World Health Organization’s World Mental Health Survey Initiative version of the Composite International Diagnostic Interview, carried out between February 5, 2001, and April 7, 2003. Participants A total of 9282 English-speaking respondents 18 years and older. Main Outcome Measures Proportions of respondents with 12-monthDSM-IVanxiety, mood, impulse control, and substance disorders who received treatment in the 12 months before the interview in any of 4 service sectors (specialty mental health, general medical, human services, and complementary and alternative medicine). Number of visits and proportion of patients who received minimally adequate treatment were also assessed. Results Of 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a nonpsychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by >1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. Conclusions Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality.
2,610 citations
"Barriers to mental health treatment..." refers background in this paper
...…proportion of adults with common mental disorders fail to receive any treatment (Kessler et al. 2005c ; President’s New Freedom Commission on Mental Health, 2005 ; Wang et al. 2005a, b, 2007a ; Sareen et al. 2007), even when these conditions are quite severe and disabling (Kessler et al. 2001)....
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TL;DR: Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment and continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments.
Abstract: Background Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders. Methods We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general...
1,699 citations
"Barriers to mental health treatment..." refers background or methods in this paper
...In Poverty in the United States : 2001....
[...]
...Twelve-month use of mental health services in the United States : results from the National Comorbidity Survey Replication....
[...]
...The NCS-R is a nationally representative household survey of respondents aged o18 years in the contiguous United States (Kessler et al. 2004, 2005a)....
[...]
...In the context of these limitations, the data provide a broad overview of perceived barriers to initiation and continuation of mental health treatments in the United States....
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...As described elsewhere (Kessler et al. 2005a), blind clinical re-interviews using the Structured Clinical Interview for DSM-IV (SCID) (First et al. 2002) with a probability subsample of NCS-R respondents found generally good concordance between WMH-CIDI diagnoses and SCID diagnoses....
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