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Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673

DOI 10.1007/s10488-006-0082-y

ORIGINAL PAPER

Subjective Unmet Need for Mental Health Services in Depressed


Children Grown Up
Rise B. Goldstein Mark Olfson
Elaine Goff Martens Susan I. Wolk

Published online: 6 July 2006


 Springer Science+Business Media, Inc. 2006

Abstract complete an additional interview about experiences


Background Limited attention has been devoted to with health care, including subjective unmet need for
characterizing unmet need for treatment among indi- and barriers to mental health treatment.
viduals with mental disorders. A longitudinal follow-up Results About 37% of respondents reported lifetime
of depressed, anxious, and psychiatrically normal chil- histories of subjective unmet need for mental health
dren into adulthood provided an opportunity to services. Unmet need was associated with female
examine factors associated with subjective unmet need. gender and lifetime mood and substance dependence
Methods Respondents (n = 208) comprise a sub- disorders. The most commonly cited barriers included
sample of a cohort ascertained between 1977 and 1985 attitudes toward treatment, not knowing where to ob-
consisting of three subgroups: one with major depres- tain it, and financial concerns.
sive disorder (MDD), one with anxiety disorders but Conclusions Subjective unmet need was common in
no MDD, and controls with no psychiatric disorder up this sample. Approaches to reducing it might include
to ascertainment. Psychiatric status was reassessed in public health initiatives to foster more favorable atti-
adulthood using the SADS-LA by interviewers blind to tudes toward treatment, increase knowledge of where
childhood diagnoses. Best-estimate diagnoses describ- to obtain it, and lower financial barriers.
ing participants lifetime clinical course were formu-
lated by senior clinicians. Participants who completed Keywords Depressive disorder Substance-related
SADS-LA interviews about themselves were invited to disorders Mental health services Utilization
Unmet need

R. B. Goldstein M. Olfson S. I. Wolk


Division of Clinical-Genetic Epidemiology, Department of
Psychiatry, College of Physicians and Surgeons of Columbia
University, New York, NY, USA Introduction

E. G. Martens R. B. Goldstein M. Olfson S. I. Wolk


Despite the considerable impairment and distress
Division of Clinical-Genetic Epidemiology, New York State
Psychiatric Institute, New York, NY, USA associated with most major mental disorders, and de-
spite the availability of effective treatments, most
E. G. Martens individuals with prevalent disorders are not currently
Department of Neuroscience, University of Connecticut
treated (Kessler et al., 2005). Even when they per-
Health Science Center, Farmington, CT, USA
ceived a need, only 59% of individuals with past-year
R. B. Goldstein (&) mood, anxiety, or substance use disorders in the Na-
Laboratory of Epidemiology and Biometry, Division of tional Comorbidity Survey sought mental health
Intramural Clinical and Biological Research, National
treatment (Mojtabai, Olfson, & Mechanic, 2002). Most
Institute on Alcohol Abuse and Alcoholism, 5635 Fishers
Ln., Rm. 3068, M.S. 9304, Bethesda, MD 20892-9304, USA individuals with lifetime disorders eventually seek
e-mail: goldster@mail.nih.gov treatment, but substantial delays are common (Kessler,

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Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673 667

Olfson, & Berglund, 1998a; Wang, Berglund, Olfson, & treatment history of adults (e.g., Wang et al., 2004, 2005;
Kessler, 2004; Wang et al., 2005). cf. Dawson, Lavori, Coryell, Endicott, & Keller, 1999).
Younger age at onset, less severe disorders, and Over such long periods of recollection, this approach is
older age at assessment in epidemiologic surveys are vulnerable to substantial recall bias (Newman & Bland,
associated with greater lifetime delays in help seeking 1998; Patten, 2003). Previous research also commonly
(Kessler et al., 1998a, b; Wang et al., 2004). However, relies on structured diagnostic interviews administered
epidemiologic studies also suggest that, in addition to a by trained lay interviewers (e.g., Aoun et al., 2004; Katz
persistent, severe clinical course characterized by sub- et al., 1997; Mojtabai et al., 2002), rather than more
stantial impairment and comorbidity (Wang et al., informative semistructured interviews that are inte-
2005), early-onset, untreated psychopathology is asso- grated with other sources of information and reviewed
ciated with adverse outcomes including school failure, by expert clinicians to yield final diagnoses.
teenage pregnancy, instability of employment, and The present study examines associations of sub-
early, violent, and unstable marriages (Forthofer, jective unmet need with demographic and clinical
Kessler, Story, & Gotlib, 1996; Kessler, Foster, Saun- characteristics in a subsample of a cohort originally
ders, & Stang, 1995; Kessler et al., 1997; Kessler, ascertained as children and followed up as adults 10-
Walters, & Forthofer, 1998b). 15 years after original ascertainment. The cohort con-
These findings indicate substantial unmet need for sists of three subgroups: one with childhood major
mental health services. However, limited attention has depression (MDD), one with childhood anxiety disor-
been devoted to defining, measuring, and characteriz- ders but no MDD, and normal controls with no psy-
ing unmet mental health treatment needs among in- chiatric disorder up to original ascertainment. This
dividuals with mental disorders. Unmet need may be sample is of particular interest given the availability of
defined objectively as the proportion of individuals longitudinal data concerning respondents clinical sta-
who meet criteria for a disorder but do not seek pro- tus in childhood and their course of illness into adult-
fessional care (e.g., Katz, Kessler, Frank, Leaf, & Lin, hood. Best-estimate diagnoses describing participants
1997). This definition has been criticized as both in- lifetime clinical course were formulated by senior cli-
sufficiently and overly inclusive. For example, some nicians based on semistructured interviews, medical
individuals who meet diagnostic criteria for a disorder records, and other sources of information. In addition,
may not experience sufficient impairment or distress the depressed and anxious subgroups were ascertained
that they perceive a need for treatment (Aoun, Pen- from tertiary-care child psychiatry clinics. Given their
nebaker, & Wood, 2004; Kessler et al., 1998a; Wang early exposure to mental health treatment, they might
et al., 2004). Conversely, individuals may experience be expected to have greater knowledge of available
severe distress, perceive a need and seek services in the services than young adults ascertained from the com-
absence of a diagnosable disorder (Katz et al., 1997). munity (cf. Blumenthal & Endicott, 1996/1997). These
Others who are symptomatic and impaired with diag- considerations, along with our respondents substantial
nosable disorder perceive a need, but nevertheless do lifetime psychiatric morbidity, yield a unique oppor-
not seek mental health treatment (perceived or tunity to investigate factors associated with subjective
subjective unmet need; Aoun et al., 2004; Katz unmet need for mental health care.
et al., 1997; Mojtabai et al., 2002).
Given these divergences between objective and
subjective indices of need, consideration of both do- Methods
mains is important in assessing the adequacy of mental
health service availability (Aoun et al., 2004). Reduc- Subjects
tions of objective and subjective unmet need for
mental health care, especially among young people All study procedures were approved by the Institu-
who meet criteria for mood, anxiety, substance use, or tional Review Board of the New York State Psychiatric
other serious mental disorders, remain key goals of Institute and the Department of Psychiatry at Colum-
public health policy (e.g., Aoun et al., 2004; Flisher bia University. Written informed consent was obtained
et al., 1997; Kataoka, Zhang, & Wells, 2002). A greater from all subjects.
understanding of the extent, distribution, and de- Respondents comprise a subsample obtained from a
terminants of subjective unmet service needs may in- clinical follow-up of a cohort consisting of three groups of
form efforts to expand service access to target groups. prepubertal children and adolescents 617 years old: (a)
Most studies of mental health treatment seeking rely 199 with MDD, (b) 65 with anxiety disorders but no
on lifetime retrospective reports of diagnoses and MDD, and (c) 175 normal controls. Selection of the

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668 Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673

original sample and clinical follow-up methods have been addition to ascertaining symptoms and dates of onset
described in detail elsewhere (Chambers et al., 1985; and offset of episodes of mental disorders, the instru-
Puig-Antich et al., 1985a, b; Weissman et al., 1999a, b). ment assesses sociodemographic characteristics and
Depressed and anxious children were recruited be- health care utilization, including the number of 6-
tween 1977 and 1985 from tertiary-care child psychia- month periods in which mental health treatment was
try clinics at Columbia University and the New York received between initial ascertainment and the follow-
State Psychiatric Institute. Subjects were screened for up interview. The SADS-LA was administered to
inclusion in the study using a rigorous 2-week diag- subjects about themselves, and to one knowledgeable
nostic evaluation protocol consisting of the Schedule adult informant about each subject, by trained clinician
for Affective Disorders and Schizophrenia for School- interviewers blind to subjects childhood diagnostic
Aged Children (K-SADS) administered by a child status. Final lifetime diagnoses were formulated by
psychiatrist (Chambers et al., 1985), intelligence test- experienced clinicians uninvolved with data collection,
ing, and a pediatric examination with Tanner staging of based on SADS-LA interviews, medical records, and
pubertal status. Subjects were classified as adolescents other available information, using a best-estimate
at Tanner Stages IIIV (Tanner, 1962). A second K- procedure (Leckman, Sholomskas, Thompson, Belan-
SADS was conducted after a 2-week interval by a rater ger, & Weissman, 1982). Each episode of each disorder
blind to the results of the earlier assessment. To qualify was diagnosed separately, including dates of onset and
for inclusion in the depressed group, children were duration. Average lifetime Global Assessment of
required to meet full Research Diagnostic Criteria Functioning Scale (GAFS) score was also estimated.
(RDC; Spitzer, Endicott, & Robins, 1978) for MDD
with or without comorbid anxiety disorders on both K- Materials and Procedures
SADS interviews. To be included in the anxious group,
children were required to meet RDC for one or more The 295 subjects who completed SADS-LA interviews
anxiety disorders without MDD on both K-SADS in- about themselves during the clinical follow-up were
terviews. recontacted between 1995 and 1997, a mean stan-
Potential subjects were excluded if they had been dard deviation of 2.6 1.3 years after their clinical
taking medications that could produce depressive-like follow-up interviews, and invited to complete the
symptoms or interfere with pituitary or hypothalamic Health Care Experiences (HC) interview. The HC in-
function. Additional exclusion criteria included: (1) cludes questions about current health insurance cover-
severe medical illness, especially endocrinopathies and age, usual sources of care, and detailed assessments of
heart disease; (2) obesity, defined as weight-height ra- lifetime experiences with mental health treatment up to
tio greater than the 95th percentile; (3) height or the time of their clinical follow-up, including subjective
weight below the third percentile; (4) clinical seizures unmet need. Subjective unmet need was defined as an
or other major neurological illness; (5) IQ below 70; affirmative response to the question, Have there been
and (6) diagnoses of autism, schizophrenia, or anorexia times when you felt you needed treatment for emo-
nervosa. Diagnostic information was obtained first tional, family, alcohol, or drug problems, but didnt get
from parents and then from the children themselves. help? Those who reported unmet need were then
Psychiatrically well child and adolescent controls asked a series of closed-ended questions about possible
were recruited contemporaneously with the ill subjects barriers to care, including financial (e.g., lack of insur-
through school systems, newspaper advertisements, ance coverage), attitudinal (e.g., belief that treatment
and word of mouth. Only children and adolescents who would not help), logistical (e.g., transportation or child
met criteria for no psychiatric diagnoses in their life- care problems), and stigma-related (e.g., worry what
times up to their original ascertainment, using the same others would think) concerns, as well as an open-ended
diagnostic procedures as were employed with the de- (other, specify) category (Pearse, 1994; Blumenthal
pressed and anxious subjects, and who met none of the & Endicott, 1996/1997).
other exclusionary criteria for the ill groups, were ac-
cepted as normal controls. Data Analysis
Of the initial cohort of 439, 76% were reinterviewed
at clinical follow-up, between 1991 and 1997. Diag- Bivariate comparisons of respondents reporting any
nostic status was assessed using the Schedule for unmet meet to those reporting none were made using
Affective Disorders and SchizophreniaLifetime two-tailed t tests for continuous variables and v2tests
Version for Anxiety Disorders (SADS-LA; Mannuzza, for categorical variables. Multivariable logistic regres-
Fyer, Klein, & Endicott, 1986) for DSM-III-R. In sion was used to estimate associations of subjective

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Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673 669

unmet need with diagnostic variables and GAFS scores respondents originally ascertained for childhood
while controlling for the potentially confounding ef- MDD, but not those selected for childhood anxiety
fects of gender, pubertal status at ascertainment, age at without MDD, than among respondents ascertained as
follow-up, and time on study. To maximize the statis- normal controls. Respondents with unmet need were
tical power afforded by the available sample, the significantly older at both ascertainment and follow-up,
GAFS score was treated as a continuous variable. more likely to have been postpubertal at ascertain-
Demographic covariates were selected for inclusion ment, and more likely at follow-up to meet criteria for
based either on statistical associations with subjective any lifetime disorder as well as any lifetime mood,
unmet need (P < 0.10) or on subject-matter consid- anxiety, substance dependence, and antisocial person-
erations (Hosmer & Lemeshow, 2000). Because age at ality disorder, based on best-estimate longitudinal
original ascertainment was highly correlated with diagnoses. However, subjective unmet need was not
pubertal status, the latter rather than the former was associated with time on study, gender, or ethnicity, nor
chosen for inclusion in the multivariable models based with marital status, educational attainment, or house-
on subject-matter considerations (Weissman et al., hold income at follow-up. Respondents with unmet
1999a, b). All demographic and clinical variables were need had significantly lower average lifetime GAFS
entered simultaneously into the final model. All anal- scores and met criteria for more total mental disorder
yses were performed using Statistical Analysis System diagnoses over their lifetimes than those without un-
software, version 8.2 (SAS Institute, Inc., 1999). met need for treatment (3.4 2.0 vs. 1.7 1.7, t
(205) = 6.17, P < 0.0001). Respondents with unmet
need received significantly more treatment during the
Results follow-up period than respondents without unmet need.

Analysis Sample Adjusted Odds Ratios

The HC interview was completed by 70% (n = 208) of After adjustment for covariates, lifetime mood and
the 295 subjects completing the SADS-LA interview substance dependence disorders remained significantly
about themselves at clinical follow-up. HC respondents associated with subjective unmet need, though the
and eligible non-respondents did not differ significantly odds ratios were smaller than those observed in the
with respect to childhood diagnosis, ethnicity, pubertal bivariate analyses. Childhood diagnosis, lifetime anxi-
status at ascertainment, age at ascertainment or follow- ety and antisocial personality disorders, age at follow-
up, marital status, household income during the year up, treatment received, average lifetime GAFS score,
prior to clinical follow-up, lifetime diagnoses of mood and time on study did not retain statistical significance.
disorder or substance dependence, or time on study. However, female gender emerged as significantly
(Data available upon request). Completers and eligible associated with unmet need. Inclusion of total number
noncompleters of the HC interview were also compa- of lifetime diagnoses in the multivariable model did not
rable with respect to the number of 6-month periods alter the odds ratios for female gender, nor for lifetime
during which they received any mental health treat- mood and substance dependence disorders. The count
ment from one year after initial ascertainment to their of total diagnoses was also not independently associ-
SADS-LA interview. The first year after initial ascer- ated with subjective unmet need (data available upon
tainment was excluded from this computation so as to request) and therefore it was deleted from the final
minimize the inclusion of treatment associated with model.
initial ascertainment. HC respondents were signifi-
cantly better educated (more college graduates) and Barriers to Care
more likely to meet criteria for lifetime anxiety diag-
noses than eligible nonrespondents. Among the 77 respondents with any lifetime diagnosis
and subjective unmet need, the most commonly cited
Unmet Need by Demographic and Clinical barriers to obtaining mental health treatment were
Characteristics logistical (e.g., not knowing where to go for treatment,
endorsed by 54%), and attitudinal. Attitudinal barriers
Bivariate Analyses included beliefs that the problem would eventually get
better by itself (66%), that problems can be solved
As shown in Table 1, subjective unmet need was without help (55%), being too busy (49%), thinking
significantly greater in bivariate analyses among that treatment takes too much time or is inconvenient

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670 Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673

Table 1 Subjective unmet need for mental health treatment by selected demographic and clinical characteristics (N = 208)
Characteristic Unmet need No unmet Crude odds Adjusted2 odds
(n = 77) need (n = 131) ratio (95% CI)1 ratio (95% CI)1

Childhood diagnosis
Major Depressive Disorder (n = 90) 46.1% 53.9% 2.4 (1.34.8)** 0.8 (0.32.0)
Anxiety Disorder (n = 31) 41.9% 58.1% 2.0 (0.94.7) 1.5 (0.54.5)
Normal (n = 87) 26.4% 73.6% 1.0 (referent) 1.0 (referent)
Pubertal status (% postpubertal) 50.7% 49.3% 2.4 (1.34.4)** 1.9 (0.57.3)
at ascertainment
Age at childhood ascertainment 11.9 3.2 10.6 3.1 1.1 (1.01.2)**
(mean SD) per year
Age at follow-up (mean SD) 24.2 3.1 22.7 3.0 1.2 (1.11.3)*** 1.0 (0.81.3)
per year per year
Time on study in years (mean SD) 12.3 2.3 12.1 2.2 1.1 (0.91.1) 1.0 (0.81.3)
per year per year
Gender (% female) 41.6% 58.4% 1.4 (0.82.5) 2.2 (1.14.5)*
Race/ethnicity
Black 25.5% 74.5% 0.5 (0.21.1)
Hispanic 42.2% 57.8% 1.1 (0.62.1)
Other 0.0% 100.0%
White 40.9% 59.1% 1.0 (referent)
Marital status at follow-up
Never married 36.5% 63.5% 1.0 (referent)
Married/remarried 41.2% 58.8% 1.2 (0.43.4)
Separated/Divorced/Widowed 50.0% 50.0% 1.7 (0.47.2)
Educational attainment at follow-up
Less than high school 39.7% 60.3% 1.4 (0.72.8)
High school diploma 31.6% 68.4% 1.0 (referent)
Some post-high school 38.9% 61.1% 1.4 (0.53.9)
college graduate 48.5% 51.5% 2.0 (0.94.5)
Household income at follow-up
< $9,999 52.2% 47.8% 1.8 (0.74.3)
$10,00019,999 24.0% 76.0% 0.5 (0.21.4)
$20,000+ 38.2% 61.8% 1.0 (referent)
Any lifetime disorder
Yes 43.7% 56.3% 24.8 (22.826.8)***
No 3.0% 97.0%
Any lifetime mood disorder
Yes 48.9% 51.1% 5.3 (2.611.0)*** 3.6 (1.58.7)**
No 15.3% 84.7%
Any lifetime anxiety disorder
Yes 46.9% 53.1% 2.2 (1.23.9)** 1.3 (0.72.7)
No 28.8% 71.2%
Any lifetime substance dependence
Yes 59.7% 40.4% 3.7 (1.97.0)*** 2.9 (1.36.3)**
No 28.7% 71.3%
Alcohol dependence
Yes 61.4% 38.6% 3.6 (1.87.2)***
No 30.7% 69.3%
Drug dependence
Yes 58.8% 41.2% 2.9 (1.46.2)**
No 33.0% 67.0%
Antisocial personality disorder
Yes 66.7% 33.3% 3.7 (1.112.6)* 2.8 (0.613.5)
No 35.4% 64.6%
Average lifetime Global Assessment of 65.2 13.4 74.0 13.5 0.6 (0.50.8)*** 0.8 (0.61.1)
Functioning Scale score (GAFS, mean SD) per 10 points per 10 points
Number of 6-month periods of any treatment since 6.9 7.0 3.8 6.0 1.1 (1.01.1)** 1.0 (0.91.1)
original ascertainment + 1 year (mean SD) per period per period
1
CI: Confidence interval
2
From final logistic regression model containing childhood diagnosis, pubertal status at ascertainment, age at follow-up, time on study, gender,
average lifetime GAFS score, total number of 6-month periods of any treatment since ascertainment + 1 year, and best-estimate lifetime
diagnoses of any mood, anxiety, substance dependence, and antisocial personality disorders based on clinical follow-up. Each parameter is
adjusted for all others in the model
*P 0.05 ** P 0.01*** P 0.001

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(49%), and thinking that treatment would not do any diagnoses as well as any lifetime diagnosis, lifetime
good (40%). Financial barriers were cited less fre- mood, and lifetime anxiety disorders, but women were
quently, including respondents beliefs that treatment less likely than men to meet criteria for lifetime diag-
was too expensive (39%) and that health insurance noses of substance dependence and antisocial person-
would not cover it (29%). ality disorder. Thus, women in our sample were not
obviously more ill or impaired than men; these results
stand in contrast to findings of community epidemio-
Discussion logic studies reviewed by Aoun et al. (2004) that wo-
men are both more disabled and more likely to
In this sample of young adults, many of whom met perceive needs for treatment than men.
criteria for multiple lifetime diagnoses and experienced Perhaps the treatment received by women over
a severe, chronic course of illness with substantial follow-up was disproportionately unsatisfactory vis-a-
psychosocial impairment (Weissman et al., 1999a, b), vis their perceived needs. Undertreatment of mood
37% reported lifetime subjective unmet need for care. (Hirschfeld et al., 1997) and substance abuse (Ethe-
In models adjusting for potential confounders, ridge, Craddock, Dunteman, & Hubbard, 1995) dis-
respondents ill as children and ascertained from ter- orders has been well documented. To our knowledge,
tiary-care child psychiatry clinics were as likely to re- the question of whether undertreatment of mood dis-
port unmet need as those psychiatrically well at orders differentially affects women has not been ad-
ascertainment and recruited from the community. The dressed. However, addictions treatment programs,
pattern and frequency of barriers to care were similar particularly coeducational ones, have been criticized
to those reported from clinical (e.g., Blumenthal & for inadequate attention to womens specific needs,
Endicott, 1996/1997) and community (Mojtabai et al., including attention to past histories of trauma as well
2002) samples. as obstetrical, gynecological, and child care concerns
The high rate of subjective unmet need for treat- (Chander & McCaul, 2003). Womens perceptions of
ment associated with addictive disorders does not need, compared to mens, could also reflect differen-
support the common clinical assumption that denial, or tially unrealistic expectations for treatment outcomes.
lack of desire to change behavior, explain low rates of However, our attempts to interpret this finding are
treatment utilization by individuals with these condi- complicated by our use of a compound probe that
tions. Instead, their unmet need may reflect being combines the concepts of perceived need and unmet
made to feel unwelcome by clinicians pessimistic need. In particular, while we assessed actual utilization
assessments of their likely prognoses (McLellan & over respondents time on study, we were unable to
Druley, 1977). evaluate the temporal relationship between perceived
The association of subjective unmet need with fe- need and either utilization or unmet need.
male gender has not, to our knowledge, been reported Additional limitations of the study include small
previously. It is possible that this difference represents sample size, which may have constrained our ability to
gender differences in perceived severity of depressive detect associations of respondents clinical character-
symptoms. As compared with adolescent boys receiv- istics with unmet need. For example, the associations
ing treatment, for example, treated adolescent girls we observed in bivariate analyses of subjective unmet
tend to report more severe depression, while parent need with childhood diagnosis, lifetime anxiety disor-
reports reveal relatively little gender disparity in de- der, and antisocial personality disorder were consistent
pression severity (Compas et al., 1997). Gender-based with small effect sizes; associations with any lifetime
differences in the response of the health care system mood disorder and lifetime substance dependence
may further contribute to the observed difference in were consistent with medium effect sizes. Using the
perceived need for treatment. Primary care physicians methods described by Cohen (1988), with a = 0.05, we
have a tendency to treat depressed women, but refer determined that our available sample of 208 respon-
men on to mental health specialists for more intensive dents yielded power of 99% to detect differences in
care (Kessler, 1986). prevalence of subjective unmet need by lifetime mood
In our sample, women and men demonstrated sim- disorder and lifetime substance dependence. Power to
ilar lifetime functioning as measured by average life- detect differences by childhood diagnosis, lifetime
time GAFS score, and utilized similar amounts of anxiety disorder, and antisocial personality disorder
treatment during the follow-up period. Gender distri- ranged from 75 to 80%. However, since most of the
butions were similar with respect to childhood sample met criteria for multiple diagnoses, power may

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672 Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673

have been insufficient to identify associations with authors express their appreciation to Dr. Weissman for her
specific disorders and take account of comorbidity. invaluable guidance on the conceptualization of this study and
her comments on drafts of this article.
Other potential limitations involve our measure of
subjective unmet need. While our question about un-
met need appears to have face validity, and is worded References
in a manner comparable to similar items in previously
published studies (Aoun et al., 2004), we have found Andersen, R., & Newman, J. F. (1973). Societal and individual
no published studies addressing the reliability or determinants of medical care utilization in the United
validity of alternative methods of assessing subjective States. Milbank Memorial Fund Quarterly, 51, 95124.
Aoun, S., Pennebaker, D., & Wood, C. (2004). Assessing popu-
unmet need for mental health treatment. In addition, lation need for mental health care: A review of approaches
we did not obtain information on when specific periods and predictors. Mental Health Services Research, 6, 3346.
of unmet need occurred and therefore cannot associate Blumenthal, R., & Endicott, J. (1996/1997). Barriers to seeking
unmet need temporally with episodes of particular treatment for major depression. Depression and Anxiety, 4,
273278.
disorders. Chambers, W. J., Puig-Antich, J., Hirsch, M., Paez, P., Ambro-
While we assessed current insurance coverage by sini, P., Tabrizi, M., et al. (1985). The assessment of affective
respondents self-report at the time they completed the disorders in children and adolescents by semistructured
HC interview, we did not obtain longitudinal infor- interviews. Archives of General Psychiatry, 42, 696702.
Chander, G., & McCaul, M. E. (2003). Co-occurring psychiatric
mation about insurance over the follow-up period. In disorders in women with addictions. Obstetrics and Gyne-
addition, we did not ascertain the availability of mental cology Clinics of North America, 30, 469481.
health professionals in respondents areas of residence Cohen, J. (1988). Statistical power analysis for the behavioral
during their time on study. Since both geographic sciences (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Asso-
ciates, Inc.
availability and insurance coverage are important Compas, B. E., Oppedisano, G., Connor, J. K., Hinden, B. R.,
determinants of access to health care (Andersen & Achenbach, T. M., & Hammen, C. (1997). Gender differ-
Newman, 1973; Shi, 2001), including mental health ences in depressive symptoms in adolescence: Comparison
treatment (Goodwin & Andersen, 2002; Mojtabai of national samples of clinically referred and nonreferred
youths. Journal of Consulting and Clinical Psychology, 65,
et al., 2002), we are unable to relate respondents 617626.
perceptions of unmet need to objective indicators of Dawson, R., Lavori, P. W., Coryell, W. H., Endicott, J., & Keller,
service accessibility. M. B. (1999). Course of treatment received by depressed
Finally, our respondents were ascertained from ter- patients. Journal of Psychiatric Research, 33, 233242.
Etheridge, R. M., Craddock, S. G., Dunteman, G. H., & Hub-
tiary-care treatment clinics for mood or anxiety disor- bard, R. L. (1995). Treatment services in two national stu-
ders, and from nonclinical sources for having no dies of community-based drug abuse treatment programs.
diagnosis, as children. Therefore, the generalizability Journal of Substance Abuse, 7, 926.
of our findings to samples ascertained from other Flisher, A. J., Kramer, R. A., Grosser, R. C., Alegria, M., Bird,
H. R., Bourdon, K. H., et al. (1997). Correlates of unmet
sources, or based on different clinical criteria, is un- need for mental health services by children and adolescents.
clear. Psychological Medicine, 27, 11451154.
That the prevalence of subjective unmet need is so Forthofer, M. S., Kessler, R. C., Story, A. L., & Gotlib, I. H.
high, even among individuals who have substantial (1996). The effects of psychiatric disorders on the prob-
ability and timing of first marriage. Journal of Health and
experience with mental health treatment, suggests that Social Behavior, 37, 121132.
the mental health care system may not be meeting the Goodwin, R., & Andersen, R. M. (2002). Use of the Behavioral
service needs of substantial numbers of persons with Model of Health Care Use to identify correlates of use of
identified disorders. Interventions to increase treat- treatment for panic attacks in the community. Social Psy-
chiatry and Psychiatric Epidemiology, 37, 212219.
ment utilization among individuals who have both Hirschfeld, R. M., Keller, M. B., Panico, S., Arons, B. S., Barlow,
diagnosable disorders and perceived needs might D., & Davidoff, F., et al. (1997). The national depressive
beneficially include public health initiatives to foster and manic-depressive association consensus statement on
more favorable attitudes toward utilization of mental the undertreatment of depression. Journal of the American
Medical Association, 277, 333340.
health services, increase knowledge of where to obtain Hosmer, D. W., & Lemeshow, S. (2000). Applied logistic
treatment, and lower financial barriers to care. regression (2nd ed.). New York: John Wiley and Sons,
Inc.
Acknowledgements This work was supported by an Aaron Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need
Diamond Foundation Postdoctoral Research Fellowship to Dr. for mental health care among U. S. children: Variation by
Goldstein at Columbia University and by National Institute of ethnicity and insurance status. American Journal of Psy-
Mental Health Grant #R01-MH50666 and a Senior Investigator chiatry, 159, 15481555.
Award from the National Alliance for Research on Schizo- Katz, S. J., Kessler, R. C., Frank, R. G., Leaf, P., & Lin, E.
phrenia and Depression to Myrna M. Weissman, Ph.D. The (1997). Mental health care use, morbidity, and

123
Adm Policy Ment Health & Ment Health Serv Res (2006) 33:666673 673

socioeconomic status in the United States and Ontario. Pearse, W. H. (1994). The Commonwealth Fund Womens
Inquiry, 34, 3849. Health Survey: Selected results and comments. Womens
Kessler, R. (1986). Sex differences in the use of health services. Health Issues, 4, 3847.
In: S. McHugh & M. Vallis (Eds.), Illness behavior: A Puig-Antich, J., Lukens, E., Davies, M., Goetz, D., Brennan-
multidisciplinary model (pp. 135148). New York: Plenum. Quattrock, J., & Todak, G. (1985a). Psychosocial functioning
Kessler, R. C., Berglund, P. A., Foster, C. L., Saunders, W. B., in prepubertal major depressive disorders, I: Interpersonal
Stang, P. E., & Walters, E. E. (1997). Social consequences of relationships during the depressive episode. Archives of
psychiatric disorders, II: Teenage parenthood. American General Psychiatry, 42, 500507.
Journal of Psychiatry, 154, 14051411. Puig-Antich, J., Lukens, E., Davies, M., Goetz, D., Brennan-
Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. Quattrock, J., & Todak, G. (1985b). Psychosocial functioning
A., Walters, E. E., et al. (2005). Prevalence and treatment of in prepubertal major depressive disorders. II. Interpersonal
mental disorders, 1990 to 2003. New England Journal of relationships after sustained recovery from the depressive
Medicine, 352, 25152523. episode. Archives of General Psychiatry, 42, 511517.
Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. SAS Institute, Inc. (1999). SAS Statistical Software, version 8.
(1995). Social consequences of psychiatric disorders, I: Cary, NC: Author.
Educational attainment. American Journal of Psychiatry, Shi, L. (2001). The convergence of vulnerable characteristics and
152, 10261032. health insurance in the U.S. Social Science and Medicine, 53,
Kessler, R. C., Olfson, M., & Berglund, P. A. (1998a). Patterns and 519529.
predictors of treatment contact after first onset of psychiatric Spitzer, R. L., Endicott, J., & Robins, E. (1978). Research di-
disorders. American Journal of Psychiatry, 155, 6269. agnostic criteria: Rationale and reliability. Archives of
Kessler, R. C., Walters, E. E., & Forthofer, M. S. (1998b). Social General Psychiatry, 35, 773782.
consequences of psychiatric disorders, III: Probability of mar- Tanner, J. M. (1962). Growth at adolescence: With a general
ital stability. American Journal of Psychiatry, 155, 10921096. consideration of effects of hereditary and environmental
Leckman, J. F., Sholomskas, D., Thompson, W. D., Belanger, A., factors upon growth and maturation from birth to maturity.
& Weissman, M. M. (1982). Best estimate of lifetime psy- Oxford, England: Blackwell Scientific Publications.
chiatric diagnosis: A methodological study. Archives of Wang, P. S., Berglund, P., Olfson, M., & Kessler, R. C.
General Psychiatry, 39, 879883. (2004). Delays in initial treatment contact after first on-
McLellan, A. T., & Druley, K. A. (1977). The readmitted drug set of a mental disorder. Health Services Research, 39,
patient: Evidence of failure or gradual success? Hospital and 393416.
Community Psychiatry, 28, 764766. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B.,
Mannuzza, S., Fyer, A. J., Klein, D. F., & Endicott, J. (1986). & Kessler, R. C. (2005). Failure and delay in initial treat-
Schedule for Affective Disorders and Schizophrenia, Life- ment contact after first onset of mental disorders in the
time Version (modified for the study of anxiety disorders): National Comorbidity Survey Replication. Archives of
Rationale and conceptual development. Journal of Psy- General Psychiatry, 62, 603613.
chiatric Research, 20, 317325. Weissman, M. M., Wolk, S., Goldstein, R. B., Moreau, D.,
Mojtabai, R., Olfson, M., & Mechanic, D. (2002). Perceived need Adams, P., Greenwald, S., et al. (1999a). Depressed ado-
and help seeking in adults with mood, anxiety, or substance lescents grown up. Journal of the American Medical Asso-
use disorders. Archives of General Psychiatry, 59, 7784. ciation, 281, 17071713.
Newman, S. C., & Bland, R. C. (1998). Incidence of mental Weissman, M. M., Wolk, S., Wickramaratne, P., Goldstein, R.
disorders in Edmonton: Estimates of rates and methodolo- B., Greenwald, S.,Ryan, N. D., et al. (1999b). Children
gical issues. Journal of Psychiatric Research, 32, 273282. with prepubertal-onset major depressive disorder and
Patten, S. B. (2003). Recall bias and major depression lifetime anxiety grown up. Archives of General Psychiatry, 56,
prevalence. Social Psychiatry and Psychiatric Epidemiology, 794801.
38, 290296.

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