In-depth interviews with 9,282 randomly selected American adults have found that unlike most disabling physical diseases, mental illness begins early in life. Half of all lifetime cases begin by age 14, and three-quarters have begun by age 24. For example, anxiety disorders often begin in late childhood, mood disorders in late adolescence, and substance abuse before age 25. The household survey did not assess relatively rare and clinically complex psychiatric disorders such as schizophrenia, which typically appears before age 25.
"There are many important messages from this study, but perhaps none as important as the recognition that mental disorders are the chronic disorders of young people in the U.S.," said Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH), which sponsored the study.
The $20 million National Comorbidity Survey Replication was a collaborative project between Harvard University, the University of Michigan, and the NIMH Intramural Research Program. It is an expanded replication of the 1990 National Comorbidity Survey, which was the first to estimate the prevalence of mental disorders by using modern psychiatric standards in a nationally representative sample. Results of the replication were reported in the June 6 issue of the Archives of General Psychiatry by Ronald Kessler, Ph.D., and colleagues.
Twenty-six percent of the interviewees reported past-year symptoms of a diagnosable disorder in the four major categories that were the focus of the study: anxiety disorders (an 18 percent prevalence rate), mood disorders (10 percent), impulse-control disorders (9 percent), and substance use disorders (4 percent). The three most prevalent 12-month disorders were specific phobia (9 percent), social phobia (7 percent), and major depressive disorder (7 percent). The most prevalent lifetime disorders reported by interviewees were anxiety disorders (29 percent), mood disorders (21 percent), impulse-control disorders (25 percent), and substance use disorders (15 percent).
The main burden of illness was found to be concentrated among persons with a severe disorder—about 6 percent of the group that reported a diagnosable disorder. A serious disorder was defined as one involving a substantial limitation in daily activities or work disability, a suicide attempt with serious lethal intent, or psychosis. Interviewees in this group reported a mean of 88.3 days—nearly three months of the year—when they were unable to carry out their normal daily activities.
High rates of comorbid disorders were also found. Nearly half (45 percent) of those with one mental disorder met criteria for two or more disorders, with severity strongly related to comorbidity.
The study also documented long delays between onset of illness and first treatment contact. The delays occurred for nearly all mental disorders, although they varied according to specific diagnostic categories. The median delay across disorders was nearly a decade. The longest delays were 20 to 23 years for social phobia and separation anxiety disorders, which the authors attributed to the relatively young age of onset and to fears of therapy that involve social interactions. The shorter but still protracted delays found for mood disorders—between six and eight years—may be attributable to public awareness campaigns, the marketing of newer therapies directly to consumers, and expanded insurance coverage.
The study found that over a 12-month period, 60 percent of interviewees who had a diagnosable disorder received no treatment. Seventeen percent of the interviewees reported use of mental health services in the past year, up from 13 percent in the 1990 National Comorbidity Survey. The expansion was mainly in the general medical sector, with more primary care physicians providing psychiatric services.
People with mental or substance use disorders were more likely to get treatment from a primary care physician or nurse or other general medical physician (23 percent) or from a nonpsychiatrist specialist (16 percent), such as a psychologist, a social worker, or a counselor, than from a psychiatrist (12 percent). The survey showed that treatment adequacy, measured by number of visits, was greater when treatment was provided by mental health practitioners. About 10 percent of interviewees sought help from a counselor or spiritual advisor outside of a mental health setting, and 7 percent used a complementary or alternative source, such as a chiropractor or self-help group.
Two New York Times articles published after the study data were released reflected the ongoing debate about what the cutoff points for clinically significance should be. The study was the third since 1984 to suggest a substantial increase in the prevalence of mental illness. In one of the New York Times articles, Darrel Regier, M.D., director of research at the American Psychiatric Association (APA), noted that a similar national epidemiologic survey in 1994 found a past-year prevalence rate of 30 percent among adult Americans; however, a reanalysis of those data that took into account whether the interviewees had sought treatment or help for their symptoms found a rate of 20 percent. In a recent statement released by APA, Dr. Regier called the new epidemiologic data "exploratory" and noted that such findings "typically need replication and validation."
The National Comorbidity Survey Replication is part of a global initiative on the epidemiology of mental disorders in 28 countries, coordinated through the World Health Organization. More information on the survey is available on the NIMH Web site at www.nimh.nih.gov.
The Center for Substance Abuse Treatment (CSAT) has released Substance Abuse Treatment: Group Therapy, the 41st in its series of Treatment Improvement Protocols (TIPs). The TIP describes group therapy and addiction treatment as "natural allies" and the group as "a source of powerful curative forces that are not always experienced by the client in individual therapy." The document distills the latest research and clinical findings into practical guidelines to help practitioners of group modalities enhance their therapeutic skills to harness the "potential healing powers inherent in a group … to foster healthy attachments, provide positive peer reinforcement, act as a forum for self-expression, and teach new social skills."
The purpose, principal characteristics, and leadership styles, skills, and techniques of five group models that are common in substance abuse treatment are described in the TIP. They include:
• Psychoeducational groups that educate clients about substance abuse
• Skills development groups that cultivate the skills needed to attain and sustain abstinence
• Cognitive-behavioral groups that help members alter thoughts and actions that lead to substance abuse
• Support groups that provide a forum for sharing pragmatic information about maintaining abstinence and managing day-to-day living
Interpersonal process groups that address major developmental issues that contribute to addiction and can interfere with recovery.
In addition to the models, three specialized types of groups are described—relapse prevention groups, communal and culturally specific groups, and groups that use expressive therapies, such as music or painting. Groups described in the TIP have trained leaders and a specific intent to treat substance abuse, a definition that excludes self-help groups such as Alcoholics Anonymous and Narcotics Anonymous.
Separate chapters in the TIP are devoted to placement criteria for matching a client to an appropriate group; group development, such as preparing clients for participation and creating group agreements that outline expectations for participation; strategies and leadership approaches for clients in the early, middle, and late stages of treatment; characteristics, duties, and concepts that are critical for effective group leadership; and group therapy training opportunities available to substance abuse treatment professionals.
The 16-member consensus panel that developed the TIP included representatives from the range of disciplines involved in group therapy and substance abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and state government officials. The chair was Philip J. Flores, Ph.D., of the department of psychology at Georgia State University in Atlanta. The panel's recommendations are attributed either to the panelists' clinical experience or to published studies. Substance Abuse Treatment: Group Therapy is available on the Web site of the National Library of Medicine at www.ncbi.nlm.nih.gov.
Kaiser reports on Medicaid spending: In light of recent discussions at the state and federal levels about restructuring Medicaid, the Kaiser Commission on Medicaid and the Uninsured has released two new reports—a data analysis and a policy discussion—on spending for persons in Medicaid's mandatory and optional eligibility categories. The analysis shows that although optional populations account for 29 percent of Medicaid enrollment, 60 percent of all spending (whether for mandatory or optional populations) is optional and 86 percent of optional spending is for elderly persons or individuals with disabilities. A third issue paper summarizes findings on the impact of increasing out-of-pocket costs for Medicaid and the State Children's Health Insurance Program (SCHIP) beneficiaries. Even modest premium increases in some states have led to the disenrollment of large numbers of beneficiaries. The reports are available on Kaiser's Web site at www.kff.org/medicaid.
Updated Treatment Facility Locator: The Substance Abuse and Mental Health Services Administration's (SAMHSA's) online Treatment Facility Locator has been updated. The locator is a searchable database of more than 11,000 programs that treat alcohol and drug use problems among adolescents and adults. The locator identifies private and public facilities that are licensed, certified, or otherwise approved for inclusion by state substance abuse agencies in all 50 states, the District of Columbia, and the federated states of Micronesia, Guam, Puerto Rico, the Republic of Palau, and the Virgin Islands. The updated locator complements SAMHSA's National Directory of Drug and Alcohol Abuse Treatment Programs, which is published annually in hard copy. A link is also provided to SAMHSA's Buprenorphine Physician Locator. The Treatment Facility Locator is available at http://findtreatment.samhsa.gov.