There has been a substantial increase in the number of children and adolescents accessing mental health services during the past 2 decades, but the majority of severely impaired individuals remain untreated, new research shows. Using nationwide survey data, investigators found although the proportionate increase in youths accessing mental health care was greater for those with more severe impairment, the number of children and adolescents with less severe impairment who received treatment doubled in absolute numbers. The findings also indicate that, notwithstanding an almost doubling of the proportion of individuals with more severe impairment accessing care since the mid 1990s, more than half still do not access mental health services. "Despite the increase in treatment, many young people with severe mental health impairment received no care," the researchers write. "In schools and primary care settings, improvements in the identification and referral of young people in the greatest need of treatment could provide community benefit." The study is published in the May 21 issue of the New England Journal of Medicine. Unnecessary Treatment? Lead author Mark Olfson, MD, MPH, New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York City, explained that the research grew out of concerns that there may be a growing number of young people who are receiving mental health treatments unnecessarily. "That concern, which really hadn't been looked at in any way empirically, was one of the primary things that motivated this study," he told Medscape Medical News. To determine trends in the outpatient use of mental health services by individuals aged 6 to 17 years, the team examined the Medical Expenditure Panel Surveys for 1996-1998, 2003-2005, and 2010-2012, yielding data on 53,622 children and adolescents. The Columbia Impairment Scale was used to classify individuals as having more severe impairment, defined as a score of ≥16, or having less severe impairment, defined as a score of <16. Between the periods 1996-1998 and 2010-2012, the percentage of young people receiving outpatient mental health care increased from 9.2% to 13.3% (odds ratio, 1.52). There was a greater proportionate increase in the use of mental health services among children and adolescents with more severe impairment than in those with less severe impairment during the same interval, at respective increases of 26.2% to 43.9% and 6.7% to 9.6%. Nevertheless, there was a greater absolute increase in service use among young people with less severe impairment than among those with more severe impairment, at increases of 2.74 million to 4.19 million patients and 1.56 million to 2.28 million patients, respectively. Looking at individual treatments, the team found that there were significant increases in the proportionate use of psychotherapy and psychotropic medications during the study period, from 4.2% to 6.0% and from 5.5% to 8.9%, respectively. Among individual treatments, increases were observed for, among others, stimulants and related medications, antidepressants, and antipsychotic medications, at respective increases of 4.0% to 6.6%, 1.5% to 2.6%, and 0.2% to 1.2%. Lower Treatment Rates in Minorities Reflecting on the findings, Dr Olfson said that one of the issues facing clinicians is that "it's difficult to determine with certainty which individual children do and don't need mental health treatment." "I think there are things in this study that suggest we are moving in the right direction, namely, the proportionate greater increase in treatment of children with severe impairment," he added. "But at the same time, we do see growth in, for example, the treatment of less severely ill kids with antipsychotic medications." Dr Olfson said this is something for which "we need to be having a very careful look" to make sure that alternative therapies, such as psychosocial treatments, are being offered. A further concern is that fewer than half of children and adolescents with severe mental health impairment were using mental health services. "Among kids from minority ethnic racial backgrounds with severe mental health impairments, the numbers are even greater; you have only around a third of them that are receiving treatment," said Dr Olfson. "Clearly, more needs to be done to get the kids who are in the greatest need of care to have treatments that they can benefit from." What does Dr Olfson believe is needed to improve the situation? He replied: "One thing this study does is it demonstrates that parents often know that their children are having serious mental health problems, but still they don't receive treatment for them." "So I'm not sure that additional sets of guidelines will really address that issue. I think what needs to happen is that primary care physicians, pediatricians, school teachers, and others who are concerned with child and adolescent health need to be actively discussing treatment options with parents who have kids with these more serious problems," he said. The study was supported by a grant from the Agency for Healthcare Research and Quality and by the New York State Psychiatric Institute. Dr Olfson reports no relevant financial relationships. N Engl J Med. 2015;372:2029-38. Abstract Source
