Two limitations of the study need to be noted. First, severity was assessed Cupcake charm and chain between 1990 and 1992 with the use of imputation, and second, the adequacy of treatment was not assessed. Both the strong relationship of imputed values to direct measures of severity in the NCS-R and the use of the multiple-imputation method to adjust for the increase in error variance when testing for significance tend to minimize concern with regard to the first limitation. The second limitation is of more concern, because research has shown that many patients with a mental disorder receive inadequate treatment.18 We were unable to study the adequacy of treatment, however, because the information on processes of care in the NCS was insufficient for such an analysis.
Our data suggest two directions for future research and policy analysis. First, Tiffany Aria pendant most people with a mental disorder do not receive treatment, efforts are needed to increase access to and demand for treatment. The persistence of low rates of treatment among traditionally underserved groups calls for special initiatives.30 The Surgeon General's report on undertreatment among racial and ethnic groups1 and the National Institute of Mental Health initiative with regard to undertreatment among men31 may provide useful models that should be evaluated. Programs to expand resources for treatmentin targeted locations might also be of value,32 as might initiatives such as legislation to encourage the use of mental health services by vulnerable elderly patients.22 Efforts are also needed to evaluate widely used treatments for which there are as yet no data on effectiveness and to increase the use of evidence-based treatments. The expansion of disease-management programs, quality-Christmas Tree charm and chain programs for treatment, and the use of "report cards" are important steps in this direction. Substantial barriers continue to exist, however, including competing clinical demands and distorted treatment incentives.33,34 Initiatives aimed at overcoming these barriers are under way.35,36 Future surveys of trends in the prevalence and treatment of mental disorders need to include data on treatment processes, such as those in the NCS-R, to permit changes in the quality of treatment to be tracked.
Supported by grants from the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the U.S. Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R01-TW006481), the Pan American Health Organization, Eli Lilly, Ortho-McNeil Tiffany Aria pendant, GlaxoSmithKline, and Bristol-Myers Squibb. The National Comorbidity Survey was supported by grants from the National Institute of Mental Health (NIMH) (R01 MH46376, R01 MH49098, and R01 MH52861), with supplemental support from grants from the National Institute of Drug Abuse (NIDA) (MH46376) and the William T. Grant Foundation (90135190), and the National Comorbidity Survey Replication is supported by a grant from the NIMH (U01-MH60220), with supplemental support from grants from the NIDA, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (044708), and the John W. Alden Trust.
The views expressed in this article are those of the authors and do not necessarily represent the views of the T&CO. horseshoe charm and chain organizations, agencies, or the U.S. government.We are indebted to the staff of the World Mental Health Data Collection and Data Analysis Coordination Centers for assistance with instrumentation, fieldwork, and consultation on the data analysis; and to Bedirhan Ustun for helpful comments on the manuscript.
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