The authors have declared that no competing interests exist.
Conceived and designed the experiments: MT GM. Analyzed the data: MT ES AB GM. Wrote the paper: MT. Conceptualization and design of the study: MT GM. Data acquisition: MT ES GM. Statistical analyses: MT AB GM. Interpretation and analysis of data: MT ES AB GM. Draft of initial manuscript: MT. Critical review of the manuscript: MT ES AB GM. Approval of the final version of the manuscript: MT ES AB GM.
School mental health services are important contact points for children and adolescents with mental disorders, but their ability to provide comprehensive treatment is limited. The main objective was to estimate in mentally disordered adolescents of a nationally representative United States cohort the role of school mental health services as guide to mental health care in different out-of-school service sectors.
Analyses are based on weighted data (N = 6483) from the United States National Comorbidity Survey Replication Adolescent Supplement (participants' age: 13–18 years). Lifetime DSM-IV mental disorders were assessed using the fully structured WHO CIDI interview, complemented by parent report. Adolescents and parents provided information on mental health service use across multiple sectors, based on the Service Assessment for Children and Adolescents.
School mental health service use predicted subsequent out-of-school service utilization for mental disorders i) in the medical specialty sector, in adolescents with affective (hazard ratio (HR) = 3.01, confidence interval (CI) = 1.77–5.12), anxiety (HR = 3.87, CI = 1.97–7.64), behavior (HR = 2.49, CI = 1.62–3.82), substance use (HR = 4.12, CI = 1.87–9.04), and eating (HR = 10.72, CI = 2.31–49.70) disorders, and any mental disorder (HR = 2.97, CI = 1.94–4.54), and ii) in other service sectors, in adolescents with anxiety (HR = 3.15, CI = 2.17–4.56), behavior (HR = 1.99, CI = 1.29–3.06), and substance use (HR = 2.48, CI = 1.57–3.94) disorders, and any mental disorder (HR = 2.33, CI = 1.54–3.53), but iii) not in the mental health specialty sector.
Our findings indicate that in the United States, school mental health services may serve as guide to out-of-school service utilization for mental disorders especially in the medical specialty sector across various mental disorders, thereby highlighting the relevance of school mental health services in the trajectory of mental care. In light of the missing link between school mental health services and mental health specialty services, the promotion of a stronger collaboration between these sectors should be considered regarding the potential to improve and guarantee adequate mental care at early life stages.
Mental disorders place a great challenge on the health care system. They are highly prevalent not only in adults
Many children and adolescents with mental disorders do not receive adequate care
The school sector has been reported to be a major contact point for children and adolescents with emotional or behavioral problems
The main objective of this study was to estimate in a nationally representative United States cohort, focusing on adolescents with a lifetime mental disorder, the role of school mental health services as guide to care in out-of-school service sectors for the treatment of mental disorders.
This study was conducted using data from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). The NCS-A, a nationally representative face-to-face survey of 10148 United States adolescents (ages 13–18 years) that was carried out in a dual-frame design between February 2001 and January 2004
Adolescents and parents provided written informed consent, and the Human Subjects Committees of both Harvard Medical School and the University of Michigan approved the NCS-A.
To examine lifetime mental disorders in adolescents, trained interviewers used the WHO Composite International Diagnostic Interview (CIDI) Version 3.0, a structured clinical interview assessing major classes of Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV disorders, including affective disorders (i.e. major depressive disorder, dysthymia, bipolar disorder I, bipolar disorder II), anxiety disorders (i.e. agoraphobia, generalized anxiety disorder, social phobia, specific phobia, panic disorder, post-traumatic stress disorder, separation anxiety disorder), behavior disorders (i.e. attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder), substance use disorders (i.e. alcohol abuse/dependence, drug abuse/dependence), and eating disorders (i.e. anorexia nervosa, bulimia nervosa, binge eating disorder). The applied version of the CIDI was computer-assisted and has been adjusted for adolescents, with ensured interview quality and concordance with a clinical reappraisal subsample
Adolescents and parents provided information on child/adolescent mental health service use across multiple sectors, based on the Service Assessment for Children and Adolescents
All statistical analyses are based on post-stratification weighted data, which allowed for the correction of minor discrepancies in distributions of school and/or sociodemographic characteristics between the sample and the population
We re-evaluated the results after adjusting
To validate our results, we conducted the following secondary analyses: To control for potential confounding, we repeated the analyses after adjusting for several sociodemographic factors, as sociodemographic factors have previously been shown to influence mental health service utilization in children and adolescents
Service utilization | |||
842 | 25.24 | ||
1908 | 55.87 | ||
1129 | 32.70 | ||
350 | 10.01 | ||
552 | 16.73 | ||
Male | 1749 | 50.42 | |
13–14 y | 1364 | 34.28 | |
15–16 y | 1428 | 41.36 | |
17–18 y | 864 | 24.36 | |
Hispanic | 475 | 15.52 | |
Black | 667 | 15.95 | |
Other | 227 | 5.10 | |
White | 2287 | 63.44 | |
Less than high school | 470 | 14.10 | |
High school | 1092 | 29.42 | |
Some college | 826 | 23.22 | |
College grad | 1268 | 33.27 | |
≤1.5 | 560 | 15.82 | |
≤3 | 711 | 20.26 | |
≤6 | 1209 | 32.47 | |
>6 | 1176 | 31.46 | |
Northeast | 674 | 16.93 | |
Midwest | 1187 | 23.93 | |
South | 1152 | 34.28 | |
West | 643 | 24.86 | |
Metro | 1506 | 46.45 | |
Other urban | 1306 | 39.31 | |
Rural | 844 | 14.24 | |
0 | 381 | 11.03 | |
1 | 1517 | 42.21 | |
2 | 1758 | 46.77 | |
Oldest | 1235 | 36.71 | |
Youngest | 1047 | 26.54 | |
Others | 1374 | 36.75 | |
0 | 161 | 4.10 | |
1 | 939 | 25.80 | |
2 | 963 | 27.92 | |
3 or more | 1593 | 42.19 |
Abbreviations: y, years.
*Subsample of the National Comorbidity Survey-Adolescent Supplement (NCS-A) including all participants providing self- and parent-reported information on mental disorders, with at least one mental disorder.
Moreover, we repeated the analyses three times, controlling for either i) number of categories in which a mental disorder was present (1/2/> = 3), ii) age of onset of the type of mental disorder characterizing the subsample in which the analysis was performed (affective disorders: 1–10 years/11–12 years/13–14 years/15–18 years; anxiety disorders: 1–4 years/5–6 years/7–10 years/11–18 years; behavior disorders: 1–4 years/5–7 years/8–12 years/13–18 years; substance use disorders: 1–13 years/14 years/15 years/16–18 years; eating disorders: 1–12 years/13 years/14 years/15–18 years; any mental disorder: 1–4 years/5–6 years/7–11 years/12–18 years; limits between the categories were defined by cutoffs as close as possible to the quartiles of the respective age distributions), or iii) presence of further types of mental disorders not characterizing the subsample in which the analysis was performed (yes/no).
We interpreted with caution all results that were statistically significant in the main analyses but not stable after Holm correction or secondary analyses.
There were a low percentage of subjects with missing information on service use and we dealt with missing data by restricting each analysis to subjects with complete data (see
Mental health specialty sector | Medical specialty sector | Other out-of-school service sector | Any out-of-school service sector | |||||||||
HR | (95% CI) | p-value | HR | (95% CI) | p-value | HR | (95% CI) | p-value | HR | (95% CI) | p-value | |
(0.84–1.63) | 0.353 | (1.77–5.12) | <0.001 | (0.95–2.91) | 0.071 | (0.86–1.57) | 0.335 | |||||
(0.85–2.84) | 0.147 | (1.97–7.64) | <0.001 | (2.17–4.56) | <0.001 | (1.41–2.82) | <0.001 | |||||
(0.85–1.95) | 0.230 | (1.62–3.82) | <0.001 | (1.29–3.06) | 0.003 | (0.92–2.45) | 0.103 | |||||
(0.70–1.91) | 0.553 | (1.87–9.04) | <0.001 | (1.57–3.94) | <0.001 | (0.92–2.34) | 0.102 | |||||
(0.02–1.79) | 0.144 | (2.31–49.70) | 0.003 | (0.15–4.95) | 0.857 | (0.13–1.83) | 0.276 | |||||
(1.11–2.77) | 0.017 | (1.94–4.54) | <0.001 | (1.54–3.53) | <0.001 | (1.17–2.49) | 0.007 |
Abbreviations: CI, confidence interval; HR, hazard ratio.
Note: All analyses are based on samples for which information on mental disorders was available from both self and parent report (N = 6483). Due to missing information on service utilization, sizes of the completer samples are as follows: Mental health specialty sector: n = 6358, Medical specialty sector: n = 6326, Other out-of-school service sector: n = 6322, Any out-of-school service sector: n = 6307). To calculate the hazard ratios, periods without any event were dropped.
Out of 6483 adolescents, 3656 adolescents (56.4%) were diagnosed with a lifetime mental disorder. Information on utilization of service sectors addressing mental health problems and on sociodemographic characteristics of the study cohort including these mentally disordered adolescents are presented in
After adjusting for multiple testing, all but the predictions for subsequent service utilization in the mental health specialty sector and in any out-of-school service sector in children and adolescents with any mental disorder remained statistically significant.
When we repeated the analyses after adjusting for either sociodemographic factors, number of categories in which a mental disorder was present, age of onset of the type of mental disorder characterizing the subsample in which the analysis was performed, or further types of mental disorders not characterizing the subsample in which the analysis was performed, levels of significance were mostly comparable to those presented in
This study, conducted with 6483 adolescents of a nationally representative United States cohort, provides as yet missing association estimates of school and subsequent out-of-school service utilization for mental problems in children and adolescents with a lifetime mental disorder. Results indicate that school services may serve as guide to certain out-of-school service sectors addressing mental disorders, especially the medical specialty sector, but not the mental health specialty sector.
Our results complement previous descriptive evidence regarding service use patterns in adolescents with mental disorders
The roles of the medical and the mental health specialty sectors in mental health care have been addressed previously. Several studies have confirmed the prominent position of the medical specialty sector in providing services for mental disorders
There is considerable evidence that sociodemographic characteristics of children and adolescents with mental disorders influence whether or not services for mental disorders are utilized; such sociodemographic characteristics include, amongst others, ethnicity, family income, different patient, parental and familial factors, health insurance coverage, and service availability
Our study has several strengths, including the large nationally representative sample
The study also has several limitations to be considered, including amongst others the cross-sectional design of the study, as previously discussed
Moreover, first, service utilization has been assessed by self-report, but the validity and reliability of such data has been challenged, especially in terms of non-response and recall bias, which is no issue in large health care utilization databases
Second, even though we controlled for several potential confounders, we cannot exclude confounding by unconsidered factors, including disorder severity. However, we did not reveal a relationship between school mental health service use and subsequent utilization of the mental health specialty sector, and controlling for number of disorder categories did not change the results remarkably, both of which suggests that disorder severity did not confound the presented results in a relevant manner.
Third, the observed associations do not inform about causal but about temporal relationships, and even though the study of causality is wanted, it remains challenging in such a large representative cohort. Until such studies are available, the elucidation of the position of the school sector in the trajectory of service use for mental disorders allows for a better understanding of common service paths of children and adolescents, as has previously been claimed
Fourth, the aim of our analyses was to estimate whether school mental health service use serves as a guide to the use of any out-of-school service sectors; however, we did not compare school service use with use of a specific out-of-school service sector regarding their prediction of service use in further sectors. Therefore, it may be interesting to scrutinize in future studies whether the here observed referral patterns are specific for school mental health services.
The clinical and public health relevance of the role of the school sector in the trajectory of service use for mental disorders in children and adolescents becomes evident against the background of the urgent need to reduce unmet mental disorder treatment demands and improve access to mental health care
The supply of mental health services in places where children and adolescents are easily accessible is only one among several action steps that have been proposed to increase access to mental health care for children and adolescents with mental disorders. Further suggestions include the improvement of access to information on available mental health care options, inclusion of children and adolescents in treatment planning, and offering assistance in finding one's way through the rather complicated service system
Whether the here presented role of school mental health services as a guide to out-of-school services for mental disorders in the United States is generalizable to other countries remains to be elucidated, as not only the school mental health system but also insurance and health care systems, including access to mental health care systems, vary considerably worldwide
Future studies should focus on the role of school mental health services in the trajectory of mental health service use in other countries. Moreover, future research should include prospective data and the integration of self-report of service utilization and service utilization databases. It will also be important to evaluate the appropriateness of the mental health service use trajectory emanating from the school mental health sector and to learn about modifiable factors influencing referral patterns of school mental health services, in order to be able to take action and guide or optimize such referral patterns, if necessary.
To the best of our knowledge, this is the first comprehensive study of the role of the school mental health sector as a guide to mental health care in out-of-school sectors, using data of mentally disordered adolescents of a nationally representative United States cohort. Results indicate that school mental health services may serve as a guide to certain out-of-school service sectors for children and adolescents with various mental disorders, especially the medical specialty sector, but not the mental health specialty sector. While highlighting the relevance of school mental health services in the trajectory of mental care, our findings also suggest to further investigate into a stronger collaboration between school mental health services and mental health specialty services in order to improve and guarantee adequate mental care at early life stages.