Correspondence
Psychiatric Outpatient Services in the United States and Canada
N Engl J Med 1997; 337:204-205July 17, 1997
- Article
To the Editor:
Kessler et al. (Feb. 20 issue)1 found that there was a higher probability of the use of psychiatric outpatient services in the United States than in Ontario among people with less severe mental illness. The authors conclude that any plans to expand insurance coverage for mental illness in the United States must address this problem. The study was population-based but severely limited the number of psychiatric disorders surveyed. Over 90 disorders were omitted, including all psychotic disorders, anorexia nervosa, all dissociative disorders, post-traumatic stress disorder, and all personality disorders except antisocial personality disorder (the one that is the least treatable). These disorders are among the most severe and expensive to treat. The authors mistakenly label people in treatment as having ``no need,'' even though the survey did not ask about many disorders.
1 ReferencesGlen O. Gabbard, M.D.
Menninger Clinic, Topeka, KS 66601Norman Doidge, M.D.
Clarke Institute of Psychiatry, Toronto, ON M5T 1R8, CanadaSusan Lazar, M.D.
George Washington University, Washington, DC 208171
Kessler RC ,Frank RG ,Edhind M ,Katz SJ ,Lin E ,Leaf P . Differences in the use of psychiatric outpatient services between the United States and Ontario. N Engl J Med 1997;336:551-557
Full Text | Web of Science | Medline
To the Editor:
The article by Kessler et al. was remarkable in at least three respects: the authors' implicit or explicit belief that the ``need'' for psychiatric treatment is mathematically correlated with number of diagnoses, that the number of outpatient visits should in some way be correlated with the ``need'' so defined, and that schizophrenia is not a significant psychiatric disorder.
Michael A. Pawel, M.D.
August Aichhorn Center, New York, NY 10023To the Editor:
One possible explanation for the differences in the proportions seeking treatment for less severe mental illness between the United States and Ontario may be that more patients in Ontario were receiving treatment from family physicians. It may be that in the context of continuing relationships with their family physicians, many patients with problems of living did not have formal psychiatric diagnoses but did receive effective care. Given that family medicine as a discipline is more widely developed in Canada, that more patients have an identifiable family physician, and that primary care is accessible to a greater proportion of patients, it is no surprise that fewer cases of minor mental illness are dealt with by the formal mental health community.
Michael Szul, M.D.
St. Joseph's Health Centre, Toronto, ON M6R 1B5, CanadaAuthor/Editor Response
The authors reply:
To the Editor: Gabbard et al. and Pawel disagree with our conclusion that the higher probability of service use for psychiatric problems in the United States than in Ontario is confined to those with low levels of need. This conclusion is based on two results, only one of which involves the diagnostic measures that are the focus of their criticisms. The first is that the higher use in the United States is confined to people who did not meet the criteria for any of the psychiatric disorders assessed in the surveys. Since we could not feasibly assess all psychiatric diagnoses in our interview, we also considered other indicators of service need. This second analysis found a higher probability of service use in the United States among people with good perceived mental health and role functioning but not among those with poor perceived mental health or impaired role functioning. This result, which our critics ignore, is inconsistent with their claim that our conclusion is due to underdiagnosis.
Szul further suggests that patients in Ontario may be more likely than those in the United States to receive care for minor psychiatric problems from their family doctors. As noted in our paper, this would explain our results only if it were also true that family doctors in Ontario are more skilled ``than their U.S. counterparts [in treating] minor psychiatric problems in a way that does not force patients to realize that their problems are emotional.'' Our data cannot address this issue. In either case, it appears that we have something to learn from our neighbors to the north, either about the treatment of minor psychiatric problems in family practice or about the allocation of treatment resources to patients with different levels of need for services.
Ronald C. Kessler, Ph.D.
Harvard Medical School, Boston, MA 02115Steven J. Katz, M.D., M.P.H.
University of Michigan, Ann Arbor, MI 48109-0376Elizabeth Lin, Ph.D.
Clarke Institute of Psychiatry, Toronto, ON M5T 1R8, Canada
