Mental illness will hit half in U.S., study says disorders often start in young people and go untreated for years -- care usually poor

mental illness in the US A once-in-a-decade survey of the mental health of Americans has found that disabling mental illness is as common as such chronic diseases as heart disease and cancer -- but strikes people at a much younger age, with more lasting impact on their lives.

About half of Americans will develop a mental disorder at some time in their lives, the survey of nearly 10,000 U.S. adults found -- with half of those cases starting by age 14, and three-quarters by age 24.

"Mental disorders are really the most important chronic conditions of youth in America," said Ronald Kessler, a Harvard Medical School epidemiologist and one of the study's leaders. "Sadly ... these early onset disorders very seldom come to the attention of the treatment system unless they're very severe."

He said the study underscores the need for early detection and treatment.

Many cases begin with mild symptoms, such as low-level anxiety or persistent shyness. Left untreated, however, they can escalate into more serious depression, disabling phobias or clinical anxiety, with debilitating consequences later in life.

Yet most Americans take years, even decades, to seek treatment -- 9 to 23 years for anxiety disorders -- if they seek treatment at all, the survey found. Moreover, when they do, only about 1 in 3 receives treatment in any given year that meets minimum standards of care, the survey found.

The findings, reported in the June issue of Archives of General Psychiatry, were based on 10,000 face-to-face interviews with people 18 and older. The survey, known as the National Comorbidity Survey Replication, is taken every 10 years to assess the mental health of the country.

"This is really a landmark study," said Dr. Thomas Insel, director of the National Institute of Mental Health, which funded the study. "It's the result of five years of research on the prevalence of mental disorders in a nationally representative sample."

The survey is the first to look at the frequency of seriously debilitating mental illness, defined as one that substantially interferes with a person's ability to function in normal roles. It found that about 6 percent of adults meet the criteria in any given year, which is comparable to rates of heart disease and cancer.

Overall, 1 out of 4 people meet the criteria for some type of mental disorder in a given year, but the vast majority of those cases are mild and not all of them need treatment, the survey found.

"We need to do a better job of figuring out which mild and moderate disorders are likely to become seriously debilitating in the future and which ones are self-limiting," Kessler said. "There's a lot of potential for working with early onset cases and doing early intervention to try to nip things in the bud."

The survey examined four categories of disorders: anxiety, such as panic and post-traumatic stress disorders; mood, such as depression and bipolar disorders; impulse-control, such as conduct and attention deficit/hyperactivity disorder; and substance abuse -- alcohol and drug abuse.

Kessler said it is "just staggering" that many of these disorders are occurring so early in life.

The average age of onset for anxiety disorders and impulse-control disorders is just 11 years old, the survey found, while substance abuse and mood disorders start later -- at average ages of 20 and 30 years old, respectively.

Occurrence of these problems early in life interferes with achieving important milestones, such as graduating from high school or college, staying in a close relationship, or holding down a job, the researchers said. Those problems, in turn, can cause lifelong problems.

"There are ripple effects through the life course," Kessler said. "These illnesses have a fundamental effect on how people's lives turn out. They are impaired before they have a chance to get their adult life on track."

The study authors did find reason for optimism. Treatment rates are higher today than they were 10 years ago. Among those with a mental disorder, 41 percent had sought help in the previous year, up from 25 percent when the survey was done in 1994.

Nevertheless, the survey found that a large number of people never seek treatment. This was particularly true of people with substance abuse and impulse control disorders: Nearly half of those who met the criteria for one of the conditions during their lives failed to get treatment.

Insel said that failure may be due in part to social stigma.

"It raises the possibility that the stigma against treatment may be even greater than the stigma against the disorders themselves, something that those of us in the profession tend not to realize," he said.

Among those who did seek treatment, there was a long lag time between the onset of problems and when they sought treatment, with average delays lasting years or even decades.

Disorders that start in childhood, although often more serious than those that start in adulthood, had the longest delays. The researchers speculated that minors may be less likely to receive timely treatment because recognition of symptoms is often low among their adult caregivers unless the symptoms are extreme.

Finally, and perhaps most depressing, the survey found that the quality of mental health care is dismal. Overall, only a third of people who had sought treatment in the previous 12 months received adequate care as defined by national professional guidelines, the survey found.

The quality of care was the worst among general medical clinics and primary care settings. Only 13 percent of patients received "minimally adequate care" in those settings, compared with about 45 percent among those seeing psychiatrists, psychologists or social workers.

Kessler acknowledged that the findings may not be entirely fair to primary care doctors because the more motivated patients -- those who are more likely to stick with their treatment -- are more likely to seek help from mental health professionals.

Primary care doctors are more likely to see those patients who come in with some physical complaint, but who turn out to be suffering from a mental disorder, he said. Such patients are less likely to stick with treatments or schedule follow-up visits.

Kessler said the survey shows that the more severe the disorder, the more likely a person is to get treatment and the more likely the treatment is to be effective. "That means the system is detecting severe cases, and that they're directing resources at those people, which is a good thing."

For milder cases, however, the system doesn't work that well, Kessler acknowledged. But he said that's not a good reason to avoid treatment.

"What's needed is that consumers need to be aware that adequate treatment is available 1 out of 3 times," he said. "But they have to be active consumers and get some understanding about what treatments are available, what's good care and what's not."

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