The recent increase in the use of outpatient mental health treatment among children and adolescents was driven in large part by expansion in care for those who have less severe impairment rather than for the severely impaired, according to a report published online May 21 in the New England Journal of Medicine.
Outpatient mental health treatment of youths is known to have increased in recent years, but the range of impairment in this age group is very wide, from “ostensibly healthy adolescents who seek mental health care to improve their academic performance to children with early-onset schizophrenia. ... Some observers worry that psychotropic and other mental health treatment of young people with less impairing conditions has increased disproportionately as a result of the recent broadening of conceptualizations of child and adolescent psychiatric disorders. Yet this concern has not been subject to empirical evaluation,” said Dr. Mark Olfson of Columbia University and the New York State Psychiatric Institute, both in New York.
Dr. Olfson and his colleagues analyzed time trends in the use of mental health services ascertained in Medical Expenditure Panel Surveys conducted by the U.S. Agency for Healthcare Research and Quality. These questionnaires are completed by nationally representative samples of households each year. The investigators focused on parental assessments of mental health functioning in 53,622 children aged 6-17 years: 15,307 youths assessed in 1996-1998, 19,450 assessed in 2003-2005, and 18,865 assessed in 2010-2012. Mental health impairment was evaluated via the Columbia Impairment Scale, a 13-item measure of interpersonal relations, psychopathologic symptoms, functioning in school, and use of leisure time.
Between the earliest and the most recent surveys, the percentage of youths using any outpatient mental health service increased significantly, as expected. This increase occurred across most subgroups of respondents, involving both children and adolescents, both boys and girls, and both whites and nonwhites. However, the increase was approximately twofold among youths with less severe impairment, rising from 2.74 million uses per year to 4.19 million uses per year. In contrast, the increase was smaller among youths with the most severe impairment, rising from 1.56 million uses per year to 2.28 million uses per year, the investigators said (N. Engl. J. Med. 2015 May 21 [doi:10.1056/NEJMsa1413512]). Some experts suggest that revisions to the DSM and aggressive pharmaceutical marketing have contributed to the increase in treatment of less severely impaired youths. “An increasing public acceptance of psychotropic medications may also have been a contributing factor,” Dr. Olfson and his associates said.
However, it is important to note that children and adolescents with severe impairment were much more likely than were the less severely impaired to use outpatient mental health services. And use of these services increased among all subgroups of severely impaired youths: both children and adolescents, both boys and girls, and both whites and nonwhites, the researchers added.