Episodes of Mental Health Treatment Among a Nationally Representative Sample of Children and Adolescents

Developmental, emotional, and behavioral conditions are now the leading causes of disability among youth in the United States (Halfon, Houtrow, Larson, & Newacheck, 2012).  These problems have been linked to negative social and physical health outcomes in adulthood (Shonkoff et al., 2012; Smith & Smith, 2010).  Although there is renewed interest among policymakers in improving mental health treatment for vulnerable children and adolescents, there is a dearth of evidence about patterns of treatment among youth in the general population that could inform policy proposals.

Most prior literature on mental health treatment relies on cross-sectional reports of current service use or service use in the prior 12 months.  Such studies have found that 20-50% of all youth with possible mental health problems used mental health treatment in a prior period, and rates were lowest for minority and low-income youth (Jensen et al., 2011; Merikangas et al., 2010, 2011).  These studies do not, however, permit researchers to assess the temporal sequence of treatment.  In our study, we separately assess factors that predict initiation of new versus ongoing treatment and examine predictors of treatment intensity once contact has been made with the treatment system.

We used data from panels 9-13 (calendar years 2004-2009) of the Medical Expenditure Panel Survey (MEPS), which interviews households about their health status and service utilization over a two-year period.  We identified a population of 2,576 youth age 5-17 years with possible mental illness, identified using validated screeners administered during the baseline.  We defined a new episode of care as any provider visits or filled prescriptions with a mental health diagnosis that is preceded by at least 12 weeks without treatment (Keeler, Manning, & Wells, 1988).  We defined “minimally adequate care” as eight or more mental health visits, or four or more mental health visits with receipt of a psychotropic medication.  We also examined length of episodes and number of visits using censored normal regression analysis.

We found that 43.9% of the sample had any episode of care.  Just under half of all episodes were initiated with a mental health specialist, versus a primary care provider (such as a pediatrician). Several variables were found to significantly decrease the probability of initiating treatment: female gender compared to male; black race or Hispanic ethnicity compared to whites; uninsured compared to privately insured; lower income; and worse physical health status.  About one third of youth received care that met the criteria for minimal adequacy. Of those with episodes, 60.9% had more than one visit.  Higher mental health impairment scores increased the probability of receiving minimally adequate care, while residence in the South decreased the probability.

Our results demonstrate a concerning pattern of low initiation and engagement in mental health care among youth with symptoms of mental health disorders, with minority youth and those in the South at particularly high-risk of not receiving adequate care.  Efforts to strengthen mental health treatment and improve care for vulnerable youth should be broadly focused, emphasizing not only recognition and access, but also continuity of care.