Psychiatry

Trends in Youth Psychiatric Treatment: The Plot Thickens

Severe youth psychiatric disorders decreasing while overall treatment rates rise

Posted Jun 24, 2015

You the public have been getting a lot of mixed messages when it comes to the state of child mental health and the number of children receiving treatment. You hear the alarm that too many children who don’t have real problems are being diagnosed and prescribed medication. Then you hear (usually different) people say that the major problem continues to be those who are suffering without any intervention, as more kids than ever are under stress. Everyone seems to have data from somewhere to back up their views.

Can everybody be at least somewhat correct? A new large study published in the esteemed New England Journal of Medicine demonstrates how easily a complex problem can be oversimplified.  The study followed over 50,000 individuals, looking at different periods over the past 2 decades: 1996-1998, 2003-2005, and 2010-2012.  Of principle interest was how many children between the ages of 6 and 17 received some kind of mental health care and whether the children getting treatment tended to be severely impacted by their emotional-behavioral problems versus having little or no impairment.

The results of this study are striking. Perhaps the broadest finding was that more youth are getting mental health treatment now (13.3%) than in the mid 1990s (9.2%).  But that is only the start, and there is something in this study for people from all different perspectives to point to and say, “See, I’m right.”

For those more inclined to be skeptical of psychiatric diagnosis and treatment, there is the following:

  • In terms of absolute numbers of children and adolescents, most of the increased mental health care went to those with less severe or no impairment.
  • Treatment with many different types of medications, including ADHD medications, antidepressants, and even antipsychotic medications, increased among the group of children with lower levels of impairment. This trend occurred despite some published guidelines that medications should not be used for milder forms of certain disorders.

At the same time, those with a more favorable view of mental health treatment can point to these findings:

  • Even among youth with more severe impairment, the rate of receiving any mental health care was less than half (43.9%).
  • The overall percentage of youth who have more impairing mental illness actually dropped (from 12.8% to 10.7%) during this period of increased treatment. While it may be tempting to think that the increase in treatment may be partially the cause of the decrease in impairing mental illness, the study cannot demonstrate causation.
  • Children and adolescents with more severe impairment were the ones who had the largest relative increase in service utilization (but since there are less of them, didn’t carry the day in absolute terms).

The study has picked up its fair share of publicity, including an article in the New York Times. One interesting development is that many media outlets are featuring the drop in number of youth with more impairing mental disorders as the primary statistic of interest, despite the fact that this finding was neither a part of the study’s title nor its abstract (a short summary of an article authors write for people who don’t want to read the whole manuscript).

For people like me who like to view themselves as passionate moderates, this study is even better, because it illustrates how misleading it can be when pundits decide that they only want to focus on half of the picture.  Are there kids out there receiving medications who probably shouldn’t be? Yes. Are there kids out there who are suffering because of a lack of treatment? Yes. These two facts side by side are inconvenient to many people.  Their juxtaposition doesn’t sell as many books. Nevertheless, to do the work that really needs to be done to make sure child mental health care is effective and appropriate, we do best, in my view, to think about the balance rather than the extremes.

@copyright by David Rettew, MD

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.