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Although many would agree that the U.S. health care "system" needs repairing, it remains important to understand the extent to which persons in need currently receive high-quality care. This requires that we consider two gaps related to the provision of care: the gap between needing and entering formal care (the engagement gap) and, once a person is in care, the gap between receipt of low- and high-quality care (the quality gap).
Each year about 30% of Americans have a diagnosable mental disorder andare thought toneed mental health care. Yet only about one-third of these persons become engaged in care, and only about one-third of these receive care of reasonably high quality. To illustrate the magnitude of these gaps: imagine that a population roughly equivalent to that of the four largest states combined (California, Texas, New York, and Florida) needs mental health care, but only those in California receive any care at all. And among Californians, only those living in Los Angeles County receive care of at least reasonable, not necessarily optimal, quality. My point is that very large segments of the population do not make it across one of these gaps. Most studies find that only about one in ten persons who need care for common mental disorders actually receive good-quality care.
The report by Alexander Young and colleagues in this issue describes those who have made it across the engagement gap but not necessarily across the quality gap. The study identified a specific pattern of care for persistent depression or anxiety disorders. Ideally, persons with a depressive or anxiety disorder who are not clinically improving would receive increasingly intensive treatment using various modalities in a stepped care fashion. Instead, the authors found a pattern of care that could be termed "inappropriately complacent." Although there are likely multiple causes for the apparent complacency, this pattern, more common in primary care, suggests that lack of appropriately aggressive treatment is a serious quality problem. Psychotherapy is especially underused.
More people in need are now crossing the engagement gap and receiving at least some mental health care, often in primary care settings. At the same time there is little evidence that the quality gap is narrowing. We have learned a great deal about the potentially tremendous negative personal and economic consequences of poor care. To improve care we cannot afford to treat mental illness complacently or to ignore either one of these gaps. The work of Young and others suggests that we need to prioritize strategies to overcome engagement barriers related to culture, stigma, or resources; to sustain effective quality improvement programs, especially in primary care; to make evidence-based psychotherapies more broadly available and accessible; and to employ a stepped care approach.
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