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1 - 2 - 3 - 4... Mental Illness Out the Door?

Based on detailed, face-to-face interviews, using the Diagnostic & Statistical Manual on Mental Disorders (DSM), 4th edition,² a research team directed by Kessler et al¹ at Harvard Medical School surveyed 9282 Americans over the age of 18 years and randomly selected from 34 states to identify the most common mental illnesses in the United States. This study, the "National Comorbidity Survey Replication," funded by the National Institutes of Health, is repeated each decade to monitor data in this area. Significant findings from this mental illness tracking survey as well as its companion report³ fall into 3 primary areas: incidence, prevalence, and treatment.

Incidence—the rate at which a certain event occurs; for example, the number of new cases of a specific disease occurring during a certain period

Over the course of a year, more than 1 in 4 US adults have some form of mental illness.

Although 40% of these cases can be classified as "mild" illness, 37% are considered "moderate" and 22% are considered "serious" (severity involved degree of disability as well as suicide plans or attempts).

The frequency of mental illness was as follows:

• Anxiety disorders (including generalized anxiety disorder, posttraumatic stress disorder, panic disorder, obsessive-compulsive-disorder, social anxiety disorder, or specific phobias), 18%
  
• Mood disorders (including depression, mania, and bipolar disorder), 9.5%
  
• Impulse-control problems (including pyromania and compulsive gambling), 9%
  
• Substance use disorders, 3.8%
  

Clearly, anxiety disorders are the most common form of mental health problems experienced by adults in the United States. They are diagnosed when a person demonstrates fear and/or dread, as well as physical signs of anxiety, that are not appropriate to the situation, cannot be controlled, or interfere with normal functioning. Major depressive disorders, one of the mood disorders, represent the leading cause of disability in the United States and in established economies worldwide.^4,5

Prevalence—the number of cases of a disease that are present in a population at one point in time

Over the course of their lifetime, nearly half (46.4%) of all Americans will meet the DSM criteria for some type of mental disorder.

• 28.8 % will experience anxiety disorder
  
• 24.8 % will experience an impulse-control disorder
  
• 20.8 % will experience a mood disorder
  
• 14.6 % will experience a substance use disorder
  
• 50 % of all lifetime mental health disorders will commence by age 14; 75 % will commence by age 23
  

The median age of onset of lifetime mental health disorders is 11 years for anxiety and impulse-control disorders, 20 years for substance use, and 30 years for mood disorders.

Treatment

In addition to replicating the 1994 study, the latest survey also attempted to gauge the care that Americans with mental illness receive. Survey findings from the companion report³ revealed that most of those with mental health problems receive no treatment or poor treatment.

• Sixty percent of Americans with mental illness do not seek any care.
  
• Only 33% of those with a mental disorder received even minimally adequate care.
  
• Of those who sought care from a physician, only 48% of those who went to a psychiatrist received minimally adequate care, whereas only 12.7% of those who went to a general practitioner received even that level of treatment.
  
• The characteristics of those most likely to delay or not seek treatment at all were older, male, member of a racial or ethnic minority, married, and poorly educated.
  

Implications

Although one might cast a skeptical glance and wonder whether the DSM diagnostic criteria for these disorders are so encompassing that psychiatric pathology has morphed from merely ubiquitous to pandemic dimensions, the comparative stability in these findings between 1994 and the ensuing decade, as well as the narrowing and refinement of these diagnoses over that time, must cause a large pause in reaching that conclusion. In addition, the sheer incidence and prevalence of these health problems as well as their potential infliction of distress, disability, and death, certainly seem to warrant more attention than they have traditionally received. The Surgeon General’s Report⁶ on Mental Health issues a clear plea for our assistance:

It is essential for first-line contacts in the community to recognize mental illness and mental health problems, to respond sensitively, to know what resources exist, and to make proper referrals and/or to address problems effectively themselves.

Critical care nurses already have so much to attend to at the patient’s bedside. Looking a little longer, assessing a bit deeper, listening a tad more attentively, reflecting on their patient’s mental health is not really asking for "more"; it’s part of what we do out there. Just one request: when you reflect on the mental health aspects of patient care, include your successes and effective interventions in your paper so we can share them with thousands of your colleagues at home and abroad.

References

1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–602.[Abstract/Free Full Text]
2. American Psychiatric Association. Diagnostic & Statistical Manual on Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 1994.
3. Kessler RC, Wai TC, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–627.[Abstract/Free Full Text]
4. Murray CJL, Lopez AD, eds. Summary: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, Mass: Harvard University Press; 1996.
5. National Institute of Mental Health. The Numbers Count: Mental Disorders in America. Available at: http://www.nimh.nih.gov/publicat/numbers.cfm. Accessed June 13, 2005.
6. Surgeon General of the United States. Mental Health: Culture, Race, Ethnicity- Executive Summary, Main Findings. Available at: http://www.surgeongeneral.gov/library/mentalhealth/cre/execsumma. Accessed June 13, 2005.

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