8. Mental Health

This chapter presents findings on mental health problems in the United States, including the prevalence of serious psychological distress (SPD) and major depressive episode (MDE) and the association of these problems with substance use and substance dependence or abuse (substance use disorder). Also reported here are the rates of treatment for depression (among those with MDE) in the past year, the percentages of adults aged 18 or older and youths aged 12 to 17 who received mental health care in the past year, and the percentage of adults who had an unmet need for mental health care in the past year.

SPD is an overall indicator of past year psychological distress that is derived from the K6 scale administered to adults aged 18 or older in the National Survey on Drug Use and Health (NSDUH). Numerical scores derived from responses to these six questions range from 0 to 24. For this report, a score of 13 or higher is considered SPD. It is notable that the data related to SPD assessed from 2004 to 2007 are not directly comparable with data from earlier years because of study design changes. Further information on the measurement of SPD, the scoring algorithm, and the study design changes is provided in Section B.4.4 of Appendix B.

A module of questions designed to obtain measures of lifetime and past year prevalence of MDE, the level of functional impairment caused by MDE in the past year, and treatment for depression has been administered to adults aged 18 or older and youths aged 12 to 17 since 2004. Some questions in the adolescent depression module were modified slightly from the adult depression module to make them more appropriate for youths. Given these differences, adult and youth depression estimates are presented separately in this chapter.

MDE is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had at least four of the seven additional symptoms reflecting the criteria for major depressive disorder as described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association [APA], 1994). It should be noted that no exclusions were made for MDE caused by medical illness, bereavement, or substance use disorders. Impairment is defined by the level of role interference reported to be caused by MDE in the past 12 months. For adults, the Sheehan Disability Scale (SDS) role domains are (1) home management, (2) work/school, (3) close relationships with others, and (4) social life. The role domains are assessed on a 0 to 10 scale with impairment categories of none (0), mild (1-3), moderate (4-6), severe (7-9), and very severe (10). The role domains for youths are slightly modified to be made age appropriate, but are assessed on the same 0 to 10 scale described for adults. The specific questions used to measure MDE and role impairment and the scoring algorithm for these responses are included in Section B.4.5 of Appendix B.

Although there is substantial overlap in the populations classified with SPD and MDE, there are important distinctions between the definitions of the two. Meeting the criteria for SPD indicates that the respondent endorsed having symptoms at a level known to be indicative of having a mental disorder (i.e., any disorder such as an anxiety or mood disorder). Meeting the criteria for past year MDE indicates that the respondent had the specific physical and emotional symptom profile indicative of MDE in the past 12 months. MDE is known to be a fairly common disorder that often has a significant impact on a person's work, home, and social life.

This chapter also presents data on mental health care among adults aged 18 or older and youths aged 12 to 17 for any type of mental health problem. Initiated in 2000, the mental health service utilization modules are asked of respondents regardless of MDE or SPD status. In the adult module, respondents are asked whether they received treatment or counseling for any problem with emotions, "nerves," or mental health in the past year in any inpatient or outpatient setting or used prescription medication for a mental or emotional condition. The treatment questions in this module are generic in that they do not ask specifically about treatment for a particular disorder, as do the questions in the MDE module. As such, subsequent references to treatment or counseling for any problem with emotions, nerves, or mental health are described broadly as "mental health service use" or receiving/needing "mental health care." It is possible for a respondent to have indicated receipt of treatment for depression without having indicated that he or she received services for any problems with emotions, nerves, or mental health.

In NSDUH, questions in the youth mental health service utilization module differ from those asked of adults. Youths aged 12 to 17 are asked whether they received any treatment or counseling within the 12 months prior to the interview for problems with behavior or emotions in the specialty mental health setting (outpatient or inpatient care), the general medical setting (pediatrician or family physician care for emotional or behavior problems), or the education setting (talked with a counselor, psychologist, or teacher, or received special education services while in a regular classroom or placed in a special classroom, special program, or special school). They also are asked for the number of nights spent in overnight facilities, the number of visits they had to outpatient mental health providers, and the reason(s) for the most recent stay or visit. Both the youth and the adult mental health questions specifically exclude treatment for problems with substance use, a topic asked about in other interview modules.

Estimates of unmet need for mental health care are reported for adults. Unmet need is established using a question that asks whether the respondent perceived a need for, but did not receive mental health treatment or counseling at any time in the 12 months prior to the NSDUH interview. This measure also includes persons who received some type of mental health service in the past 12 months, but reported a perceived need for additional services they did not receive.

It is important to note that because the survey covers the U.S. civilian, noninstitutionalized population, persons residing in long-term psychiatric or other institutions continuously throughout the year were not included in the NSDUH sampling frame. Persons who were hospitalized or institutionalized for a period of time during 2007, but who resided in households during the rest of the year, were included in the sample.

8.1. Adults Aged 18 or Older

Prevalence of Serious Psychological Distress among Adults

• In 2007, there were an estimated 24.3 million adults aged 18 or older in the United States with SPD in the past year. This represents 10.9 percent of all adults in this country, a rate similar to the SPD rate in 2006 (11.3 percent) (Figure 8.1), but below the rate in 2004 (12.2 percent).

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Figure 8.1 Serious Psychological Distress in the Past Year among Adults Aged 18 or Older, by Age: 2006-2007

Difference between this estimate and the 2007 estimate is statistically significant at the .05 level.

• Rates of SPD in 2007 were highest for adults aged 18 to 25 (17.9 percent) and lowest for adults aged 50 or older (7.0 percent).
• The prevalence of SPD in 2007 among women aged 18 or older (13.4 percent) was significantly higher than among men in that age group (8.2 percent).
• In 2007, rates of past year SPD were lowest among Asians at 6.4 percent. Rates for other racial/ethnic groups were 10.2 percent among Hispanics, 10.5 percent among blacks, 11.3 percent among whites, 11.9 percent among Native Hawaiians or Other Pacific Islanders, 13.7 percent among American Indians or Alaska Natives, and 14.0 percent among persons reporting two or more races.

Mental Health Service Use among Adults with Serious Psychological Distress

• Among the 24.3 million adults aged 18 or older with SPD in 2007, 10.8 million (44.6 percent) used mental health services in the past year. Among all adults with SPD, 38.8 percent received prescription medication, 27.3 percent received outpatient services, and 5.1 percent received inpatient services for a mental health problem in the past year. Respondents could report more than one type of service used.
• Among those with SPD who reported receiving mental health services in the past year, 47.2 percent received one type of care (inpatient, outpatient, or prescription medication), 45.9 percent received two types of care, and 6.9 percent received all three types of care (Figure 8.2).

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Figure 8.2 Number of Types of Mental Health Services Received in the Past Year among Persons Aged 18 or Older with Past Year Serious Psychological Distress Who Received Mental Health Services in the Past Year: 2007

Note: The three types of mental health care are receiving inpatient care, outpatient care, or prescription medication.

Serious Psychological Distress and Substance Use and Dependence or Abuse among Adults

• Past year illicit drug use in 2007 was higher among adults aged 18 or older with SPD (28.0 percent) than among adults without SPD (12.2 percent). Similarly, the rate of past month cigarette use was higher among adults with SPD (42.1 percent) than among adults without SPD (23.9 percent).
• Among adults aged 18 or older with past year SPD in 2007, the rate of binge alcohol use (drinking five or more drinks on the same occasion [i.e., at the same time or within a couple of hours of each other] on at least 1 day in the past 30 days) was 32.2 percent, which was higher than the 24.0 percent among adults who did not meet the criteria for SPD. Similarly, the rate of heavy alcohol use (drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days) among adults with SPD in the past year was higher (10.9 percent) than the rate reported among adults without SPD in the past year (6.9 percent).
• SPD in the past year was associated with past year substance dependence or abuse in 2007. Among adults aged 18 or older with SPD, 22.1 percent were dependent on or abused illicit drugs or alcohol. The rate among adults without SPD was 7.6 percent.

Mental Health Care among Adults with Co-Occurring Serious Psychological Distress and Substance Use Disorders

• Among the 5.4 million adults aged 18 or older with both SPD and substance dependence or abuse (i.e., a substance use disorder) in 2007, 46.5 percent received mental health care or substance use treatment at a specialty facility; 10.4 percent received both mental health care and specialty substance use treatment, 33.3 percent received only mental health care, and 2.8 percent received only specialty substance use treatment (Figure 8.3).

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Figure 8.3 Past Year Mental Health Care among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder: 2007

Prevalence of Major Depressive Episode among Adults

• In 2007, 7.5 percent of adults aged 18 or older (16.5 million people) had at least one MDE in the past year (Figure 8.4). Almost 1 in 20 adults (4.6 percent or 10.1 million people) had a past year MDE with severe impairment. The rates of past year MDE and MDE with severe impairment were stable between 2006 and 2007.

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Figure 8.4 Major Depressive Episode in the Past Year among Adults Aged 18 or Older, by Severe Impairment, Age, and Gender: 2007

Note: Respondents with an unknown level of impairment were included in the estimates for Major Depressive Episode without Severe Impairment.

• The past year prevalence of MDE in 2007 was lowest for those aged 50 or older (5.8 percent). The rates were similar among persons aged 18 to 25 (8.9 percent) and those aged 26 to 49 (8.5 percent).
• The past year prevalence of MDE was higher among adult females than among adult males (9.5 vs. 5.3 percent). Among women, past year MDE rates were higher in the younger age groups (11.9 percent for 18 to 25 year olds, 11.0 percent for 26 to 49 year olds) compared with those 50 or older (7.2 percent).
• Among adults aged 18 or older, past year prevalence of MDE varied by race/ethnicity in 2007. The rate of MDE was lowest among Asians (2.9 percent), while rates for other groups were 12.1 percent among persons reporting two or more races, 9.2 percent among American Indians or Alaska Natives, 8.1 percent among whites, 6.3 percent among Hispanics, and 6.1 percent among blacks.
• Among adults aged 18 or older in 2007, past year prevalence of MDE with severe impairment was higher among unemployed persons (10.2 percent) than among persons employed full time (3.6 percent), persons employed part time (5.2 percent), and persons not in the labor force (5.7 percent).

Major Depressive Episode and Substance Use and Dependence or Abuse among Adults

• In 2007, adults aged 18 or older with past year MDE had higher rates of past year illicit drug use than those without MDE (27.4 vs. 12.8 percent). A similar pattern was observed for specific types of past year illicit drug use, such as marijuana, cocaine, heroin, hallucinogens, inhalants, and the nonmedical use of prescription-type psychotherapeutics.
• Among adults aged 18 or older with MDE in the past year, 10.4 percent were heavy alcohol users in the past month, higher than the 7.1 percent of heavy alcohol users without MDE in the past year. Similarly, among adults with past year MDE, the rate of daily cigarette use in the past month was 28.7 percent, while the rate was 15.2 percent among adults without past year MDE.
• Having MDE in the past year was associated with past year substance dependence or abuse. Among adults aged 18 or older who had MDE in 2007, 21.5 percent were dependent on or abused alcohol or illicit drugs, while among adults without MDE 8.2 percent were dependent on or abused alcohol or illicit drugs (Figure 8.5). Adults with past year MDE were more likely than those without MDE to be dependent on or abuse illicit drugs (8.8 vs. 2.1 percent) and alcohol (17.0 vs. 7.0 percent).

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Figure 8.5 Substance Dependence or Abuse among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2007

Treatment for Major Depressive Episode among Adults

• Among adults aged 18 or older who had past year MDE in 2007, 64.5 percent received treatment (i.e., saw or talked to a medical doctor or other professional or used prescription medication) for depression in the same time period, which was lower than in 2006 (69.1 percent). Among persons aged 50 or older who had MDE in the past year, the treatment rate decreased from 85.4 percent in 2006 to 74.2 percent in 2007. Of adults aged 18 or older who had past year MDE with severe impairment in 2007, 72.2 percent received treatment, similar to the rate in 2006 (74.1 percent).
• In 2007, women aged 18 or older who had MDE in the past year were more likely than men to receive treatment for depression in the past year (68.0 vs. 57.8 percent), though the treatment rate for women was significantly lower than in 2006 (73.7 percent).
• Among adults aged 18 or older with past year MDE in 2007, approximately half of those with no insurance (49.3 percent) received treatment for depression in the past year compared with higher rates for those with insurance: 64.4 percent of adults with private insurance, 76.7 percent of adults covered by Medicaid or CHIP, and 77.6 percent of adults with other health insurance (including Medicare, CHAMPUS, TRICARE, CHAMPVA, VA, and other sources of health care or insurance). The rates of treatment for adults with private health insurance and other health insurance decreased from 2006 (71.1 and 86.8 percent, respectively).

Mental Health Service Use and Unmet Need for Mental Health Care among Adults

• In 2007, 29.4 million adults (13.2 percent of the population 18 years or older) received mental health services during the past 12 months (Figure 8.6). This was similar to the rate in 2006 (12.9 percent).
• In 2007, the type of mental health services most often received by adults aged 18 or older was prescription medication (11.1 percent), followed by outpatient services (6.9 percent). Rates of prescription medication and outpatient service use in 2007 were similar to the rates in 2006 (10.9 and 6.7 percent, respectively). Respondents could report receiving more than one type of mental health care.

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Figure 8.6 Past Year Mental Health Service Use among Adults Aged 18 or Older, by Type of Care: 2002-2007