Two-Thirds of Depression Victims Untreated, Study Says

Fewer than one-third of people suffering from serious depression or an anxiety disorder receive proper medical treatment, according to a large, national study conducted by researchers at UCLA and Rand Corp., a Santa Monica think tank.

The treatment shortfalls are especially striking for African Americans, the elderly and the young--and exist though most people in the study had contact with doctors.

The reasons for the problem, said experts, range from embarrassment about bringing up the subject with a doctor to poor availability of treatment.

The nationally representative study of about 10,000 people builds on the findings of the December 1999 surgeon general’s report on mental health, which highlighted the national problem of mental illness. Neglect exists, the report said, despite medicine’s ability to effectively treat these often life-crippling conditions.

“It’s a pretty terrible situation that the vast majority of people don’t get good treatment for mental health problems,” said Ronald Kessler, professor of health care policy at Harvard Medical School, whose own work has identified mental health care inadequacies.

In the UCLA-Rand study, published in the January Archives of General Psychiatry, Dr. Alexander Young of UCLA and colleagues identified 1,636 people who had a strong likelihood of suffering from one or more of several mental illnesses: major depression, a chronic, lower-grade depression called dysthymia and an anxiety disorder.

The diagnoses were based on a short interview--done in 1997 and 1998--that asked key questions about people’s mental state. Participants also were asked about any treatment they had received.

Fully 83% of the people with depression or anxiety disorder had seen health care providers for some medical reason or other in the year preceding the interview, the authors found. But only 30% had received any appropriate treatment for their psychological disorders.

People who had seen primary care providers were far less likely to have received appropriate care for mental disorders than those who had seen mental health specialists. Only 19% of the former received such treatment versus 90% of the latter.

But those who had seen only primary care physicians were far less likely to think they needed such treatment--and thus, presumably, to bring the subject up with doctors.

Those least likely to have gotten appropriate care were: blacks, men, people with less than a high school education, and those younger than 30 or older than 59.

Presence or absence of health insurance, at least in this study, made little difference to the rates of appropriate care--perhaps, the authors said, because the rates of care are so low across the board.

There are many reasons why people with depression and anxiety disorders don’t end up getting proper treatment.

“You can probably lay a bit of blame on everybody,” said Dr. Daniel Ford, associate professor of medicine, health policy and management at Johns Hopkins University School of Medicine.

Often, people don’t seek help because they are ashamed of the stigma of mental illness--or don’t recognize that they have a condition that needs treatment.

“It’s not like depression is like a spot on the skin--people don’t necessarily know what they have. They just feel bad,” said Dr. Kenneth Wells, professor of psychiatry and biobehavioral sciences at UCLA and a senior research scientist at Rand. Wells is principal investigator of the study.

And people who are depressed often aren’t thinking clearly, said Brian Jacobs, president of the California chapter of the National Alliance for the Mentally Ill. “You’re asking the organ that has the disorder to diagnose itself,” he said.

But there are many other reasons experts cite. Not everyone has good, affordable access to mental health care, even if they have health insurance. And primary care doctors need to do a much better job of identifying depression and anxiety disorders in patients and then treating them properly--no mean challenge, given the scant time patients get with doctors under managed care.

“Dealing with mental disorders takes time--you have to engage the person, ask a few open-ended questions. You have to make it feel all right to talk about this,” said Bruce Link, professor of public health at Columbia University in New York. “Physicians don’t have a lot of time.”

The authors said that the method used in the study to identify depression and anxiety is not exact, and may have included some people who didn’t have a mental problem. But they and other experts said that mild symptoms, if not dealt with, can grow and become debilitating.

And in other ways, the study overestimates the rates of adequate care, they said. Appropriate treatment was defined very generously in the study as at least two months on medication or four sessions of psychological counseling--bare minimums for each. It is generally recommended that patients take antidepressants for six to eight months, said Herbert C. Schulberg, professor of psychology and psychiatry at Weill Medical College of Cornell University in New York City.

“To find that so few people were being treated for major depression--even for only two months--is rather an appalling statistic,” Schulberg said.

Efforts are underway to beef up detection and treatment at health care plans such as PacifiCare and Kaiser Permanente. Health officials there are focusing on educating workers about mental illness, providing anonymous, self-diagnostic screens for mental disorders, and improving education for doctors and other health care providers.

In an article published last year, Wells’ group found that training health care workers and restructuring primary health care plans to improve access to mental health services resulted in long-lasting, improved treatment and quality of life for patients.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Handling Mental Problems

Percentage of adults with a probable depressive or anxiety disorder who visited a health care provider or received mental health treatment during 1997-98:

*--*

Adults with Adults with Adults with depressive depressive anxiety and anxiety disorder disorder disorders Visit with primary care practitioner 78% 84% 85% Visit with mental health specialist 18% 13% 28% Appropriate use of medication 16% 18% 30% Appropriate use of counseling 15% 11% 29%

*--*

*

Sources: UCLA, Rand Corp.