Treatment of mental disorders for adolescents in Mexico City
G Borges a, C Benjet a, ME Medina-Mora a, R Orozco b, PS Wang c
In Mexico,1 as elsewhere, only a minority of adults with psychiatric disorders receive some form of treatment.2–5 However, it is unclear to what extent this situation is similar for Mexican adolescents. Some studies of adult populations have shown that younger adult cohorts are more likely to receive care than older cohorts.6 However, other studies, mostly conducted in developed countries, have begun to shed light on important shortfalls in the mental health care received by adolescents.7–12
In 2001–2002, the National Institute of Psychiatry in Mexico conducted the Mexico National Comorbidity Survey,1 which is part of WHO’s World Mental Health Survey Initiative.13,14 Results for the urban Mexican adult population showed that fewer than one in five respondents with a 12-month prevalence of a psychiatric disorder used any service during the previous year and only one in every two respondents who used services received care that met minimal standards for adequacy.3 In 2005, the National Institute of Psychiatry in Mexico conducted the Mexican Adolescent Mental Health Survey employing similar methodology.15 We report here the rate of mental health service use in the previous year among these adolescents, the adequacy of treatments, and potential determinants of service use and treatment adequacy.
The survey was designed to be representative of the 1 834 661 adolescents aged 12–17 years that are permanent residents of private housing units in the Mexico City metropolitan area. The final sample included 3005 adolescent respondents selected from a stratified multistage area probability sample. In all strata, the primary sampling units were census count areas cartographically defined and updated by the Instituto Nacional de Estadística, Geografía e Informática.16 All households within these city block units with adolescents aged 12–17 years were selected. One eligible member from each of these households was randomly selected. The response rate of eligible respondents was 71%.
Fieldwork involving face-to-face interviews in the homes of the selected participants was carried out from March through August 2005 by interviewers who had received training in the Composite International Diagnostic Interview according to the WHO protocol stipulated for participating World Mental Health countries. A verbal and written explanation of the study was given to both parents and adolescents. Interviews were administered only to those participants for whom a signed informed consent from a parent and/or legal guardian and the adolescent was obtained. Although an adult had to be present in the home during the course of the interview, interviewers attempted to interview the adolescent privately, i.e. in another room. All study participants were given a mental health resources card with the contact information for different institutions where they could seek services should they wish to do so. The Human Subjects Committee of the National Institute of Psychiatry approved the recruitment, consent and field procedures.
Psychiatric disorders, service use and potential correlates were assessed in the Mexican Adolescent Mental Health Survey using the computer-assisted adolescent version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-A).17 The WMH-CIDI-A was adapted from the adult version WMH-CIDI 3.0 used in the Mexico National Comorbidity Survey and validated in diverse countries and cultures.18 The diagnostic sections are similar to the adult version except that the language has been simplified to be more easily understood by younger respondents, examples were made more age appropriate (e.g. references to school instead of work), and criteria were changed to accommodate caveats made for adolescents in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Prevalence of mental disorders
The 12-month prevalence of the following categories of psychiatric disorders were recorded: affective disorders (major depressive disorder, bipolar I and II disorder and dysthymia with hierarchy); anxiety disorders (panic disorder, agoraphobia without panic disorder, social phobia, specific phobia, separation anxiety disorder, generalized anxiety disorder and posttraumatic stress disorder); impulse control disorders (intermittent explosive disorder, oppositional-defiant disorder, conduct disorder and attention-deficit/hyperactivity disorder); and substance use disorders (alcohol and drug abuse and dependence).
Mental health service use
Information was collected about the use of mental health services, including the type of professionals visited, use of self-help, support groups or hotlines, and school-based programmes. The number of treatment visits made was also assessed and respondents could endorse as many professionals and treatment options as they had used in the previous 12 months.
Care received in the 12 months before the survey was categorized into the following sectors: (i) any mental health specialty provider, including psychiatrists, psychologists, counsellors, psychotherapists, mental health nurses and social workers in a mental health specialty setting; (ii) general medical practitioners, including family physicians and paediatricians; (iii) human services, including outpatient treatment with a religious or spiritual adviser or a social worker or counsellor in any setting other than a specialty mental health setting; (iv) complementary-alternative medicine and internet use, including self-help groups, any other healer, such as a herbalist, a chiropractor, or a spiritualist and other alternative therapy; and (v) school-based programmes that consisted of any special schools, special classes within a school and school-based therapies.
Minimally adequate care
Available evidence-based treatment guidelines for primary care19 and specialty mental health providers20–24 were used to define minimally adequate treatment during the previous 12 months as receiving: (i) minimally adequate psychotherapy, consisting of four or more outpatient visits to any provider25,26; (ii) minimally adequate pharmacotherapy, consisting of two or more outpatient visits to any provider and treatment with any medication for any length of time;27 or (iii) reporting still being “in treatment” at the time of the interview. Although this definition is broader than the one that we used previously,28 it allowed us to obtain conservative estimates of minimally adequate treatment across sectors. In sensitivity analyses, a more stringent definition of minimally adequate treatment was also used in which we required: (i) eight or more visits to any service sector for psychotherapy, or (ii) four or more visits to any service sector and 30 or more days taking any medication for pharmacotherapy.
Assessment of sociodemographic correlates
Information was collected on sex, age and family grouping, i.e. whether participants lived with both parents. Participants were considered students if currently enrolled. Adolescents were asked whether they worked during the school year, whether they were ever married and whether they had children. All three conditions represent an additional social burden not typical of most adolescents; therefore, participants answering affirmatively to any of the three were categorized as having social burdens. Adolescents were asked about the educational attainment of each of their parents. Parental education was then categorized as none/primary (≤ 6 years of education), secondary (7–9 years of education), high school (10–12 years of education) or college (≥ 13 years of education) and the score of the parent with the highest level of education was used. Parent-reported family income was categorized into low, average and high.
The data were weighted to adjust for differential probabilities of selection and non-response. Post-stratification to the urban Mexican adolescent population according to the 2000 census in the target age and sex range was also performed. Standard errors for proportions were obtained by the Taylor series linearization method with SUDAAN software (RTI International, Research Triangle Park, NC, United States of America).29 Logistic regression analysis30 was performed to study demographic correlates. Two parallel analyses were performed, one for receiving any treatment among those with disorders and a second one for receiving minimally adequate treatment among those with disorders who received any treatment. Odds ratios and corresponding standard errors from logistic regression coefficients were also obtained with SUDAAN and 95% confidence intervals (CIs) were adjusted for design effects. Statistical significance was evaluated with two-sided design-based tests with the 0.05 level of significance.
Table 1 shows that 9.1% of the adolescents used any service for emotional problems, with a higher use of services among those with a disorder (13.7%) compared to those with no disorder (6.1%). Respondents with a substance-use disorder reported the greatest use of services, and those with an anxiety disorder the lowest. For those with any disorder, the health-care sector was the most widely used for mental health services (by 9.5%), with school-based treatments being next most frequent. Most services delivered by the health-care sector were provided by mental health specialists, with minimal participation of the general medical sector. The disorder with the highest level of treatment was drug abuse with dependence (38%, largely treated in the non-health care system), followed by conduct disorder (25%, largely treated in the health-care system; data not shown).
Among those with a psychiatric disorder, 80% used only one type of provider, 17% two types of providers, and 3% used three or more types of providers. Among those that used two providers, the most common combination was for health care and school-based providers. About 72% of those used both services simultaneously, while 18% used school services first and later reported the use of a health-care provider. In the health-care sector, the mean number of visits was 7.8 for those with a psychiatric disorder and 6.2 for those without a disorder; for the non-health-care sector it was 19.1 and 16.5 visits respectively, and for school-based services it was 14.9 and 16.9 visits, respectively (results are not shown).
Table 2 presents the adequacy of treatment. Overall, 58.4% of those receiving any services obtained any treatment that could be considered minimally adequate, with anxiety disorders showing the lowest percentage and substance use disorders the highest. Those with a disorder were more likely to receive adequate treatment than those without a disorder and the health-care sector showed the lowest level of adequacy.
In sensitivity analyses using our more stringent definition, the proportion of respondents obtaining minimally adequate treatment among those with disorders receiving any services decreased to 27.2%; this proportion varied between 22.2% among respondents with substance disorders to 36.8% among those with affective disorders. (The results are not shown but are available upon request from G Borges.)
Table 3 presents sociodemographic correlates of receiving any services, as well as receiving minimally adequate treatment, among respondents with 12-month prevalence of these disorders. Females and those whose parents had higher levels of education were more likely to use services. Those attending school and adolescents without any “social burden” had increased, but not significantly, odds ratios of receiving treatment. The only significant correlate of receiving adequate treatment among those with a psychiatric disorder receiving any treatment was those currently attending school.
The greater likelihood of service use and adequacy of services for those attending school may be related to school-based programmes being exclusively available for this group only. For this reason, we refitted our models to obtain results for health care and non-health care services separately. In these analyses, respondents attending school were no more likely to get health care or non-health care services than those not attending school. Nevertheless, those attending school still had a significantly increased likelihood (odds ratio: 11.6; 95% CI: 3.5–38.2) of receiving adequate health care compared to those not attending school (data not shown).
Table 1. Proportion of respondents to the Mexican Adolescent Mental Health Survey being treated by health-care professionals over 12 monthsa
Table 2. Proportion of adolescents receiving minimally adequate treatment from professionals over 12 monthsa
Table 3. Sociodemographic predictors of treatment over 12 monthsa,b
Less than one in seven adolescents with any psychiatric disorder in the last 12 months used any services. Although this is the first time that representative service use data are available for adolescents in Mexico, prior research among adults in Mexico also showed that the majority of people with a recent psychiatric disorder did not receive recent treatment.3,31,32 Comparable data from other developed countries confirms the large unmet need that adolescents face.8–12 A study of another Latino population in Puerto Rico7 showed that only 26% of adolescents affected by mental disorders used services. Our results reveal the even larger gap that adolescents in Mexico face, with only 14% of those with a disorder using any service in the prior 12 months. Data for comparison on service use in other Latin American countries are lacking, although the situation of scarce resources, as well as few services and personnel for treating children having a mental disorder, is commonplace in the region.33 The lack of resources in Mexico City may be similar to other less-developed countries, although more research is needed before we can generalize our findings. Respondents without a disorder comprised about 40% of the population using services, raising concern that scarce resources for mental health care may be misallocated. However, some services may be used by respondents with lifetime histories of disorders; other respondents without apparent disorders may also be using services appropriately for primary prevention, subthreshold symptoms that do not qualify as full-blown disorders or for disorders not assessed by our survey.
Our results on the percentages receiving minimally adequate care (58%) as well as a more stringent definition (27%) are very low and similar to rates reported among adults in Mexico,3 suggesting that the entire system of care for mental disorders is in need of reform. The system for child mental health care in Latin America has been described as excessively focused on serious and rare disorders.33 A recent evaluation of psychiatric care in Mexico34 concluded that it is still mainly provided by large public psychiatric hospitals. Even though this study did not focus specifically on adolescents, these conclusions could well apply to youth.
There are many potential reasons for failure to receive minimally adequate care. Individuals with mental disorders, especially those with the most serious and impairing forms, may suffer from considerable stigmatization and discrimination associated with their mental disorder32 and may lack the ability and resources to consistently access mental health treatments.35 Patients may also find prescribed treatments intolerable.36 Providers may lack the training to recognize and properly diagnose mental disorders or lack the knowledge concerning optimal treatment regimens.37–39 These results may not be surprising, given the dearth of mental health resources in Mexico.40 It is noteworthy that there is only one child psychiatric hospital in the entire country, located in Mexico City.
Two sociodemographic characteristics predicted the use of mental health services among subjects with psychiatric disorders, being female and having more educated parents. Some studies find adolescent males to be more likely to receive services than females,41 but others have failed to do so.8,10,11,42,43 It is not clear why in this Mexican sample, females with psychiatric disorders were more likely to get services, but it is possible that the Mexican culture, that emphasizes protection of young females more so than males, could play a role or that deviant behaviour is tolerated more in males than females. More educated parents may be more likely to recognize symptoms of distress and mental disorders in their child and be able to seek treatment.44 It is possible that these adolescents have more supportive environments or more assistance in promoting treatment adherence. Although Mexico is a country with low socioeconomic status and the lack of financial resources may help explain the low rate of service use, we did not find an association between income and receiving any treatment or minimally adequate treatment – a lack of association also reported from other studies in developed countries,8 but not all.42,43
The Mexican Adolescent Mental Health Survey is a household survey with a limited response rate (71%), representing adolescents living in one of the largest metropolitan areas in the world, where health services are more available and so these results may not be generalized to other urban or rural areas of Mexico. Furthermore, we did not interview institutionalized or homeless adolescents, we only assessed a limited subset of DSM-IV disorders, and those more affected by mental illness may be more likely to have been non-respondents. Although the WMH-CIDI-A was adapted from the adult version used in the Mexico National Comorbidity Survey and validated in another Spanish-speaking country,18 the reliability and validity of the adolescent version used in this survey has not yet been established in Mexico. This set of limitations may have caused us to underestimate the unmet needs for mental health treatment and minimally adequate treatment.
In addition, we used a definition of minimally adequate treatment created for the adult population.5,13 Although some investigators45–50 have shown that treatments conforming to recommendations in evidence-based guidelines improve clinical outcomes, we are not aware of studies that validated our exact definition of minimally adequate treatment for this population.
Finally, we only examined relationships between a small number of patient or family factors44 and service utilization, type and adequacy; we did not have the ability to investigate other potentially important variables, such as the characteristics of service providers. All variables assessed were subject to misclassification which, especially if differential, could have introduced bias. Finally, we cannot conclude that factors associated with receiving any treatment, or minimally adequate treatment, are related causally because of the study’s cross-sectional nature.
Improvement in the mental health care of Mexican youth is urgently needed and should not depend only on additional services and resources. Our results shed light on an enormous public health problem facing Mexico. The large majority of those with needs received no treatment from any sector. The negative public health consequences of such unmet needs for treatment in adolescents are likely to be large. In this context, the development of additional mental health resources is sorely needed and an essential first step. However, reallocation of services and providers will be needed to take advantage of the resources that are made available. Active outreach, school-based programmes employing brief screens may be needed for the accurate identification of children with mental disorders. Interventions to train non-health care professionals to recognize children with mental health conditions and make referrals for health care may also be useful. Finally, even among Mexican youth with mental disorders from families with financial means, addressing out-of-pocket costs and other economic barriers may also be critical for increasing the generally low intensity and widespread inadequacy of mental health treatments. ■
The authors thank the staff of WHO’s World Mental Health Survey Initiative for assistance with instrumentation, fieldwork and data analysis.
Funding: The Mexican Adolescent Mental Health Survey, Corina Benjet PI, was supported by the National Council on Science and Technology in conjunction with the Ministry of Education (grant No. CONACYT-SEP-SSEDF-2003-CO1-22) and by the National Institute of Psychiatry Ramon de la Fuente Muñiz (DIES- 4845).
Competing interests: None declared.
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