The rate of severe mental illness among children and adolescents has dropped substantially in the past generation, researchers reported Wednesday, in an analysis that defies public perceptions of trends in youngsters’ mental health.

So begins The New York Times’ front-section coverage of a big paper in a big journal with a big result.

This paper, just published by The New England Journal of Medicine, considers the rate and treatment of childhood mental health impairment. In contrast to other surveys, this paper didn’t find a rise in the rate of mental illness. (Contrast this finding with the comment of a former president of the American Psychiatric Association that such illnesses are “an epidemic hidden in plain view” – that is, obviously there but underreported historically.)

Explains the lead author, Dr. Mark Olfson:

The finding is robust and real and challenges the prevailing stereotype that young people are somehow more vulnerable to mental problems.

Dr. Mark Olfson

How common is mental impairment among children and adolescents? How has this changed in recent years? How are patients being treated? Are we prescribing more than in the past? Olfson et al. seek answers to these important questions in “Trends in Mental Health Care among Children and Adolescents” – this week’s Reading.

Here’s what they did:

· The data was drawn from the Medical Expenditure Panel Surveys conducted by the Agency for Healthcare Research and Quality.

· The sample included all people between 6 and 17 years of age.

· The dataset included responses from 53,633 participants across three time periods, 1996-98, 2003-05, 2010-12. (!)

· The analysis considered impairment – measured by the parent version of the Columbia Impairment Scale (CIS), a 13-item measure of interpersonal relations, psychopathological symptoms, functioning at school and use of leisure time. It also considered use of mental health services and use of prescription medications.

Here’s what they found:

· “The percentage of young people with more severe mental health impairment (CIS score ≥16) declined from 12.8% in 1996–1998 to 11.9% in 2003–2005 to 10.7% in 2010–2012…” (!!!)

· “Among users of outpatient mental health services, the percentage with more severe mental health impairment did not change significantly between 1996–1998 and 2010–2012…”

· “The percentage of young people using any outpatient mental health service increased significantly between 1996–1998 and 2010–2012.”

· “The use of psychotropic medications, including stimulants, antidepressants, and antipsychotic agents, increased significantly over the course of the three periods…” (!)


· “The percentage of youths who received psychotherapy increased from 4.2% in 1996–1998 to 5.0% in 2003–2005 to 6.0% in 2010–2012 (odds ratio, 1.46; 95% CI, 1.21 to 1.75).” That trend applied to both patients with more severe impairment and those with less severe impairment.

Several thoughts:

1. Obviously, this is a surprising finding.

The big finding is a big deal: according to this paper, the percentage of young people with more severe mental health impairment declined from 12.8% (1996-98) to 10.7% (2010-12).

This finding isn’t just somewhat different than other recent surveys, it’s the exact opposite. Indeed, just a couple of years ago, the CDC issued a major report suggesting that severe mental illness affected 13-20% of American youths, and that this percentage was rising over time (autism rose from one in 110 to one in 88 in just two years according to that study). This paper from The New England Journal of Medicine used a different methodology – and a better one.

2. There is good news here.

We seem to be heading in the right direction: access to care is up, particularly for those with severe mental impairments, and more youths get talking therapy (not just medication management).

3. There are unresolved issues here.

The use of medications for youths is not without controversy. Some have argued that there is a big push to prescribe stimulants, in part because of the influence of the pharmaceutical companies. This study’s authors weigh in:

The findings of this analysis partially support the view that treatment of less severely impaired youths has driven the recent increase in child and adolescent outpatient mental health care. The increase in outpatient mental health treatment included approximately twice as many young people with less severe impairment as young people with more severe impairment, and roughly two thirds of new treatment episodes continued to involve youths without severe impairment. Revisions to the DSM and pharmaceutical marketing have been hypothesized to contribute to the increase in the treatment of less severely impaired young people. An increasing public acceptance of psychotropic medications may also have been a contributing factor.

4. There is bad news here, too.

A majority of young people with “more severe mental health impairment” didn’t get outpatient mental health services. That’s right: a majority.

This is an American study drawing on American data. But the story is familiar to all of us in mental health – whether you see patients in Toronto, Ontario, or Toledo, Ohio. The need of those with severe mental illness is great, and too often unmet. And, yes, minorities get less access even when they get access (pills, no talk).

And so it is that as an adult psychiatrist, I look at this NEJM paper on youth and have a strange and unfortunate sense of familiarity.

This is a good study – but, as is so often the case when we consider access to psychiatric services, the concluding thought is the same: we have much work to do.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.