Each year, more than 33 million Americans seek treatment for mental and substance use (M/SU) disorders, but deficiencies in health care quality and access prevent many of them from receiving the treatment they need, the National Academy of Science's Institute of Medicine says in a recent 600-page report. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series discusses the personal and national consequences of these deficiencies and proposes strategies for improvement. NIDA is one of eight cosponsors of the report, the second in a series that examines the quality of health care in the United States.
Numerous studies have documented a discrepancy between care that is known to be effective and care that is actually delivered, the report says. A review of studies published from 1992 through 2000 assessing the quality of care for M/SU conditions—which include alcohol withdrawal, bipolar disorder, depression, panic disorder, psychosis, schizophrenia, and substance abuse—found that only 27 percent reported adequate rates of adherence to established clinical practice guidelines. Less than a quarter of patients treated for depression received care that meets minimum standards, according to a 2003 study.
"The data suggest that people with M/SU disorders don't get the care they need. This is especially true in the general medical sector, where most patients are initially seen or treated for psychiatric and substance abuse disorders. Referrals that could be made at this point in treatment often are not made," says Dr. Paul Appelbaum, director of the Division of Psychiatry, Law and Ethics at Columbia University College of Physicians and Surgeons and a member of the committee that wrote the report.
These deficiencies have serious consequences. Together, major depression and drug and alcohol abuse and dependence are the leading causes of disability for American women and the second highest for men, behind heart disease. Moreover, M/SU disorders co-occur with a substantial number of illnesses, such as heart disease and cancer, and adversely affect the results of treatment. About one-fifth of patients hospitalized for heart attack, for example, suffer from major depression, and post-heart attack depression roughly triples one's risk of dying from a future attack or other heart condition. Mental and substance use disorders are also major risk factors for suicide.
"The report encourages coordination and complete integration of care so that patients who receive substance abuse treatment don't have to go to the other side of the city for general medical care," Dr. Appelbaum adds.
Strategies for Improving Care
The report recommends that the U.S. Department of Health and Human Services establish a high-level office to take the lead in coordinating M/SU reforms. Other recommendations include:
- Establishment of a stronger infrastructure for M/SU care by improving the synthesis and dissemination of effective, evidence-based treatments.
- Enhanced collaboration between M/SU services and general health care, as well as between providers of mental health services and their counterparts in the substance abuse field.
- Development of national standards for credentialing and licensing M/SU providers.
- Use of quality measures by government and private purchasers of health care.
- More widespread use of information technology to maintain and distribute medical records, information about quality care, and clinical support systems.
"Technology can facilitate attainment of all the other recommendations in our report," Dr. Appelbaum observes. "It would give all stakeholders access to common medical records, with appropriate protections for patient privacy, and give purchasers a way to judge the quality of the services for which they are paying."