Mental care found subpar as need grows

Among the one-quarter of Americans who suffer from mental disorders each year, many more seek treatment now than a decade ago, but most of the care they receive is inadequate, a major new national survey finds.

The survey, released yesterday, indicates that mental illness tends to start early: by age 14 in half of all cases. The survey also found that while most mental disorders are mild, 6 percent of Americans in any given year are seriously debilitated by them.

The study shows that mental illness has as great an impact on Americans as other common maladies such as diabetes or heart disease, but it tends to start decades earlier, said Ronald C. Kessler, professor of healthcare policy at Harvard Medical School, who led the survey.

''Mental disorders are really the most important chronic conditions of youth in America," he said, but ''sadly, they very seldom come to the attention of the treatment system unless they're very severe."

He and his colleagues recommended more research into how to identify and treat the milder youthful precursors of serious mental illness.

The federally funded $20-million survey, conducted every 10 years by trained academic researchers, involved face-to-face interviews at home with more than 9,000 randomly chosen people. It found that among this nationally representative sample, mental illness remained about as prevalent as it was 10 years ago: nearly half of those surveyed had experienced some form of mental illness at some point in their lives, and about a quarter in the last year.

About 18 percent of the respondents had sought mental health treatment in the past year, up from 13 percent in the 1994 survey. Of those with a mental disorder in a given year, 41 percent sought help -- up from 25 percent in the 1994 survey.

Of those who sought treatment, less than a third received proper care as defined by national professional guidelines on aspects such as the number of visits to care providers.

Advances in treatment had ''generated hope that mental disorders are being treated much more effectively than in the past," Dr. Philip S. Wang, a Harvard professor, and colleagues wrote in one of the papers generated by the study and released yesterday by the Archives of General Psychiatry.

''Our results suggest such optimism is premature," they added.

The study also found long delays, often of several years or more, between the onset of mental illness and a patient's decision to seek care. Most worrisome, Kessler said, was that ''the younger you are when it starts, the more serious it gets, but the younger you are when it starts, the less likely you are to get treatment.

''Those two things have not been known," he added. ''We're seeing the big underbelly of this beast we'd never seen before, and that's quite striking."

Improper care and delays in treatment could explain another finding -- that mental illness rates have not declined despite the increase in treatment, Kessler said.

Examples of inadequate care, he said, would include doctors prescribing a 5-milligram dose of Prozac when the minimal therapeutic dose is 20, and patients getting just two or three visits for psychotherapy, when no therapy has been shown to work in less than eight. Healthcare finances and insurance are often skewed against optimal care, he said, but patients are also sometimes at fault.

In recent years, patients have become more likely to seek mental health treatment from their primary care doctors, he said, but such patients tend to be less committed to treatment than patients who seek out psychiatrists and psychologists.

Doctors also often lack the resources for adequate care, such as an on-call psychiatrist to consult or bring in to assist patients.

For the first time, the latest survey tracked impulse-control disorders, including intermittent explosive disorder to attention-deficit/hyperactivity disorder. It found impulse disorders in general to be surprisingly common, second only to anxiety disorders and affecting 25 percent of the respondents some time during their lives. They also tended to be more severe than anxiety or substance-abuse disorders.

In the survey, the patients did not self-diagnose; rather, the interviewers used World Health Organization survey tools that were designed to generate formal diagnoses.

Among other findings, the survey also indicated that a person who has one mental disorder is highly likely to develop another, and that there is a strong correlation between multiple disorders and being more severely disabled.

''We found that about 45 percent of those with one mental disorder also met criteria for two or more, and that the severity of mental disorder is directly associated with the degree to which people manifest more than one disorder," said Kathleen Merikangas, the lead National Institute of Mental Health researcher on the survey.

Kessler said the data highlighted a patient's troubles can be compounded: A young person who is painfully shy, phobic, or depressive as a teenager might turn to drug or alcohol abuse to dull the pain; might then drop out of high school or have children out of wedlock; and at age 25 seek help. ''But it's a decade too late," Kessler said.

The mental illnesses can be treated, but the damage to that person's life cannot be undone, he said.

Nationally, controversy has been building recently around federal proposals to screen children and teenagers for mental illness, but Kessler said that screening is not the main problem: The precursors of serious mental illness are often obvious, and the dysfunction is clear. The trouble, he said, is that not enough is known about when and how to initially treat mild symptoms.

While the study found no significant decline in mental illness, it did find that since World War II, the trend of rapidly rising prevalence finally seemed to be flattening out. It is not clear whether the increase over the last 50 years, and the recent flattening, reflect real changes in prevalence or simply changes in self-reporting of mental illness. But still, Kessler said, ''It's the first decade we've been able to say with pretty good assurance that there has not been a rise in the prevalence of mental disorders."

Carey Goldberg is reachable at goldberg@globe.com.