In this issue of the Journal, Costello and colleagues present data on the use of a wide range of mental health services in the Great Smoky Mountain Study—a population-based cohort of 1,420 adolescents in the southeastern United States. The investigators found that two-thirds of youths with mental health needs received no services, and many services that were obtained were done so in agencies not designed to provide mental health care. Their results illustrate how general-population epidemiologic data can be useful for achieving two important public health goals: conducting services research to identify unmet need for effective treatment; and informing the design, testing, and targeting of interventions to address these needs.
In terms of the first goal, their results provide a stark reminder of the enormous work that lies ahead in identifying unmet needs for effective treatment, particularly among children and adolescents with mental disorders. The majority of those with needs received no treatments in any setting—a finding consistent with observations in the general U.S. population that most people with recently active mental disorders received no services in the previous year and that youth is associated with an even greater likelihood of being underserved (1). The clinical and public health consequences of such large unmet needs for treatment in children and adolescents are unknown but may be much more than just the immediate experience of morbidity and suffering. Data from studies with prospectively followed, clinically referred youths and from retrospective studies with representative community samples suggest that untreated disorders may become “gateways” to the development of comorbid disorders, with comorbidity associated with a more serious clinical course (2).
Poor functional outcomes, such as school failure, unstable employment, teenage childbearing, and marital instability or violence, are also associated with untreated mental disorders in youths (3–5) and may help explain why so many of those with psychiatric disorders in the investigators’ cohort ended up being seen outside traditional settings for mental health care delivery. Using parents’ and children’s reports of mental health service use across 21 formal and informal settings, Costello and colleagues demonstrated that, of the less than one-third of adolescents who did receive services, many received care in educational, social service, and juvenile justice agencies not designed or adequately equipped to provide mental health care. The authors’ assessments of a wide variety of service use also allowed them to document the high economic costs attributable to mental disorders in youths—costs that the investigators observed can double when more severe sequelae, such as comorbidity, are allowed to develop.
In terms of the second goal, that of informing the design, testing, and targeting of interventions to address unmet needs for effective treatment among youths with mental disorders, Costello and colleagues’ results also suggest a broad agenda for future research. Clinical trials conducted specifically with children and adolescents are sorely needed to help establish what are effective and safe treatment regimens in these populations (6). Further testing to identify optimal intensities, durations, combinations, sequences, and subgroups for treatments can help achieve another critically important goal—ensuring that interventions are personalized. However, the finding that the majority of youths with disorders were never seen or were seen in settings not primarily designed to provide mental health treatments suggests an agenda that goes beyond just the development and testing of effective, cost-effective, and personalized psychopharmacologic and psychotherapeutic modalities. School-based programs employing brief self-report or informant scales may be needed for the identification of children with mental disorders that otherwise go undetected (7).
The frequency with which youths with mental illness are seen and treated in non-mental health settings also suggests that interventions to train non-health care professionals to recognize children with mental health conditions and make referrals for health care should be explored. Active outreach and demand management interventions may be needed to encourage timely treatment seeking as well as to improve the intensity and quality of the treatments received by children with mental disorders (8). For example, future research might explore the utility of the stepped-care models or collaborative care models that are employed with adult populations (9) in order to apply the appropriate level of care and to enhance treatment resources for children in schools, pediatric general medical, or other nonspecialty settings.
The finding that youths with public health insurance were more likely to receive services in health care sectors than their peers with either private insurance or no insurance suggests that out-of-pocket costs and other financial barriers may need to be overcome to improve access to mental health care. Given the magnitude of the problem and its likely multifaceted nature, it may be essential to develop and test an armamentarium of such interventions to improve care as well as clinical and functional outcomes for youths with mental disorders. Finally, when effective, cost-effective, and personalized interventions are found, research to identify the best means of widely disseminating them will be crucial.
As Costello and colleagues point out, there are some potential limitations to keep in mind when interpreting their results. Some have to do with the self-report nature of their data on service use and the possibility that such information contains inaccuracies and biases. The authors also did not consider the appropriateness or adequacy of the services received by the youths in their study. However, to the extent that such limitations are an issue, the unmet needs for effective treatment documented in their study may be underestimated. A final potential limitation worth considering is the generalizability of their results, which are based on a predominantly rural sample in western North Carolina that oversampled American Indians but contained relatively few African Americans and other traditionally underserved groups. Any loss of generalizability may be possible to detect when these results are compared with the patterns of service use in additional cohorts, such as the National Comorbidity Survey of Adolescents, sponsored by the National Institute of Mental Health. In the meantime, Costello and colleagues’ findings suggest that considerable work lies ahead for services and interventions researchers to ensure that children and adolescents with mental disorders in this country receive effective treatments.
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Address correspondence and reprint requests to Dr. Wang, National Institute of Mental Health, Division of Services and Intervention Research, 6001 Executive Blvd., Room 7141 MSC 9629, Bethesda, MD 20852-9629; firstname.lastname@example.org (e-mail).
The views expressed here are those of the authors and do not necessarily represent those of NIH or the U.S. government. The authors report no competing interests.