Mental Health Service Use and Unmet Needs for Care in Individuals with Schizophrenia in the US

Ramin Mojtabai, Laura Fochtmann, Roman Kotov, Su-Wei Chang, Thomas J Craig, Evelyn Bromet
European Psychiatric Review, 2011;4(2):112-116
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Abstract

In the US, many individuals with schizophrenia in the community receive no or little mental healthcare for long periods of time. Their other health- and social care needs also are often unmet. Even among individuals who do receive some form of mental healthcare, the quality of care in usual treatment settings often falls short of evidence-based standards, especially with regard to psychosocial treatments. The expansion of managed care has further eroded the use of psychosocial treatments and, in some settings, continuity of care. Perhaps as a result of substandard treatment, at least half of schizophrenia patients in usual treatment settings in the US continue to experience significant symptoms. As the country’s healthcare system moves toward broader health insurance coverage and greater parity between mental and physical healthcare, improving the accessibility and quality of services for patients with severe mental disorders remains a formidable challenge.
Keywords
Schizophrenia, mental health services, unmet needs, continuity of care, managed care
Disclosure Ramin Mojtabai has received research funding and consulting fees from Bristol-Myers Squibb. The remaining authors have no conflicts of interest to declare.
Received: January 11, 2010 Accepted March 10, 2011
Correspondence: Ramin Mojtabai, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Room 797, Hampton House, 624 North Broadway, Baltimore, MD 21205, US. E: rmojtaba@jhsph.edu

The efficacy of pharmacological and psychosocial interventions in the management of schizophrenia is well documented.1,2 However, in the US, many individuals with schizophrenia in the community receive little or no treatment and, among those who do, the quality of that treatment often falls short of evidence-based guideline recommendations.3–12 Many service systems are ill-prepared to meet the other needs of these patients, which include supported employment, medical care and treatment for substance use disorders. In this article, we present an overview of patterns of unmet need for treatment in patients with schizophrenia with regard to the rate, quantity and course of service use, and the content and quality of services used. We discuss data from general population surveys and studies of first-admission patients to assess rate, quantity and course of service use, and data relating to the conformance of treatments with evidence-based benchmarks among patients in usual clinical settings to assess the quality and content of services. Our overview focuses on studies from the US; however, where appropriate or in cases where there are few US studies, we also discuss studies from other countries.

Treatment Patterns in the Community
The Epidemiologic catchment area (ECA) study of the early 1980s was the first in a new generation of general population epidemiological studies that used explicit criteria and algorithms to derive diagnoses and estimate prevalence of disorders, including schizophrenia.13 In the ECA study, among individuals with diagnoses of schizophrenia and schizophreniform disorders – according to the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) – with active symptoms in the past six months, only 57 % had received some form of outpatient mental healthcare during those past six months, 40 % of which was from the speciality mental health sector.13

The rates of service use in the other landmark US epidemiological survey, the National comorbidity survey (NCS) of 1990–1992, were quite similar to those reported in the ECA.14 However, building on the low concordance between diagnoses based on lay-administered interviews and diagnoses based on clinician-administered, semi-structured interviews, the NCS used clinician interviews and a broader category of ‘non-affective psychoses,’ including schizophrenia, schizophreniform disorder and other non-affective psychoses. The NCS found that, among the clinician-identified cases, 57.9 % of patients had used some form of mental health services in the past year, of which 47.5 % were speciality mental health services.15

The next wave of the NCS, the US National comorbidity survey-replication (NCS-R), was conducted between 2001 and 2003. To estimate the predicted prevalence of 12-month clinician-diagnosed DSM-IV non-affective psychoses, the NCS-R used a significantly modified ascertainment scheme and sophisticated statistical modeling to minimise false-positive responses.16 Of the patients with non-affective psychoses thus identified, 57.8 % reported having had mental health treatment contacts in the past 12-month period, 49.8 % of whom had been treated in the mental health speciality sector.16

The differences in the sampling frames, age ranges, diagnostic criteria, interview instruments and ascertainment methods make comparisons between these three US surveys very difficult.17,18 The difficulty is compounded by the inaccuracies inherent in estimating the prevalence of rare conditions in population samples.19 Nevertheless, the similarity in treatment patterns of individuals with schizophrenia across the three population surveys is remarkable. About 57–58 % of individuals with active symptoms of schizophrenia in the six to 12 months prior to interview reported having received some form of mental health treatment during that time. In the NCS and NCS-R, between 47.5 and 49.8 % of patients received treatment in the mental health speciality sector. Thus, based on these data, it can be deduced that at least 40 % of individuals with actively symptomatic schizophrenia spectrum disorders have no consistent contact with required services, and that more than half of them have no contact with the mental health speciality sector. These numbers reflect a large degree of potential unmet need for treatment among individuals with schizophrenia living in the various US communities.

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