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The US is making improvements in treating childhood mental illness — but not fast enough

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National survey of US parents shows that we've still got a long way to go

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The number of young people receiving mental health treatment is growing, but most kids with severe mental health impairment still don't receive care for their symptoms.

And many kids who do receive some treatment receive "too little."

More children with depression were prescribed antidepressants in 2012 than in 1996, according to a study published today in the New England Journal of Medicine. That's worrisome, since treatment guidelines suggest monitoring a child's behavior as a first line of treatment. Of course, the changes may also reflect a decreased stigma around depression, or an increased awareness that depression can strike young.

Fewer than half of young people with severe mental health impairment received treatment for these problems in 2012, despite the considerable suffering associated with leaving these issues untreated, remarks Michael Schoenbaum, an epidemiologist at the National Institute of Mental Health who didn’t work on the study. And many kids who do receive some treatment receive "too little," he says — or the wrong kind.

Right now, about one out of five children experience a mental disorder each year, according to the CDC. And the US spends about $247 billion on the treatment of childhood mental disorders. These disorders — conditions like autism spectrum disorder, ADHD, and depression — are common, and they're costing kids a lot, both economically and emotionally. That's why it's crucial for researchers to get a handle on how good we are at spotting these issues early on, and providing kids with the care they need.

In the study, researchers looked at data from over 50,000 youths age six to 17, gathered through three nationally representative surveys of parents spanning 1996 through 2012. The surveys asked the parents a number of questions about behavioral issues their child might be experiencing, in addition to questions about their children’s medical diagnoses.

one out of five children experience a mental disorder each year

By analyzing the parents’ answers, the scientists determined that the percentage of youths who are receiving outpatient mental health treatment increased to 13.3 percent from 9.2 percent over a period of 16 years. In addition, the rates of treatment increased more for non-white kids, which is encouraging given that the initial treatment rates were disproportionately low for non-white youths, Schoenbaum says. The biggest increase was seen in kids with more severe impairments, however — meaning kids with impairments that impact their education and their interactions with others. That number grew to 43.9 percent in 2012 from 26.2 percent in 1996.

The survey also asked parents about their kids' medications. The results show that the proportion of kids taking drugs like stimulants, antidepressants, and antipsychotics increased to 8.9 percent from 5.5 percent. This contrasts with other reports that found that use of antidepressant medications among young people declined or at least leveled off after the FDA’s issued a warning about potential health risks in 2004, Schoenbaum notes.

Olfson et al. (2015)

"We looked at the fraction of kids who received any antidepressants, but not the number or quantity of antidepressant prescriptions they received," says Mark Olfson, a psychiatrist at Columbia University and a co-author of the study published today. This could explain at least a portion of the difference in results. Previous studies also didn’t look at the 16-year period presented here, he says. So although there may have been a dip in prescriptions after 2004, this study may actually be showing a subsequent rebound.

The proportion of youths taking psychotropic medications increased

And it wasn't just severely ill kids who were prescribed medication more often, either. A greater proportion of kids with "less severe or no mental health impairment" were taking drugs in 2012, compared with rates recorded in 1996. This is concerning because clinical guidelines recommend active monitoring rather than anti-depressant use as a first approach in the care of children and adolescents who suffer from depression and exhibit mild-to-moderate symptoms, the authors write. But Schoenbaum isn’t as worried by this finding because he says that it's possible that the results are actually indicating a benefit resulting from the care they're receiving — care that also includes drugs. "A child might have little or no impairment because she or he has been receiving treatment," he says.

What’s particularly interesting is that while the number of kids using mental health services increased, there was also a gradual, but significant decrease in the percentage of kids with serious forms of mental health impairment — a result that Schoenbaum calls "surprising" given recent and contradictory results from the CDC.

"A smaller percentage of parents told us that their kids have this severe impairment."

Over time, "a smaller percentage of parents told us that their kids have this severe impairment," Olfson says. Other studies have focused on the number of diagnoses that children receive — a number that may say more about the kind of access they have to care rather than the number of kids displaying symptoms of severe mental health impairment.

"We don't know the cause of this change, and it sort of cuts against what I think is a common perception, that in recent years there's been an increase," Olfson says. There have been a lot of reports describing an increase in ADHD and autism among kids, and it's generally been assumed that these diagnoses are becoming more common, he says. "But we find, in a general way, that the reverse is true," he says.

There are some limitations to this work. For one thing, the latest survey was conducted between 2010 and 2012, "and the world's changed some since then — whether these trends will continue to the present day, we certainly don't know that," Olfson says. The study also didn’t break down the data into specific mental health problems, like ADHD and depression, so it’s hard to know what some of the parents’ answers mean. Finally, Olfson points out that the survey doesn’t give the researchers much information about why these changes are occurring. "So we see that more kids are being treated, but we still have a lot of kids with serious problems who aren't receiving treatment — and we don't know why."

"It looks like we’re moving in the right direction."

The study was well done overall, Schoenbaum says. "The authors were careful and responsible in their analyses and in their findings and conclusions." And, more importantly, the results are encouraging. Given the increase in outpatient mental health service use among kids with serious mental health impairment and the apparent decline in frequency of such impairment, "it looks like we’re moving in the right direction," he says.

But even with these changes, the majority of young people with serious mental health impairment aren’t receiving help from trained professionals. "At minimum, this highlights that there are still high levels of unmet need for mental health care among young people," Schoenbaum says — even if it may also be the case that some young people receive drugs despite having little or no mental health impairment.