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LETTER |
Correspondence: Requests for reprints should be sent to Ramin Mojtabai, MD, PhD, MPH, Department of Psychiatry and Behavioral Sciences, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003 (e-mail: rm322{at}columbia.edu).
McVeigh and Wunsch-Hitzig raise important points about my analyses and recommend further analyses to examine the prevalence of treatment contacts among more severely distressed individuals (those with K6 scores 
19) and to examine urban–rural differences in the prevalence of significant psychological distress and in treatment contacts. I have performed such analyses.
Of the 196 101 adult participants in the National Health Interview Survey from 1997 through 2002, only 1372 (0.6%) met the narrower criteria for significant psychological distress (K6 19). Among these, only 39.6% had any contact with mental health professionals in the past year, 22.7% reported that they could not afford mental health care, and 35.4% reported that they could not afford medications. Between 1997 and 2002, there was an increase in the proportion of participants with significant psychological distress (defined by K6 19) who had any contact with mental health professionals (from 37.4% to 43.8%, P = .04). The trends from 1997 to 2002 in the proportion of participants who reported that they could not afford mental health care (from 18.9% to 25.8%, P = .24) or that they could not afford medications (from 35.9% to 38.0%, P = .51) were not statistically significant owing to the considerably smaller sample size. However, the direction of these trends was consistent with the results of my earlier analyses.
Independent estimates (e.g., Rohrer et al.2) of the 1-month prevalence of serious mental illness are 4 to 5 times higher than the prevalence of narrowly defined significant psychological distress (K6 19) that I used here and are more consistent with the 3.2% prevalence of broadly defined significant psychological distress (K6 13) that I reported in my November 2005 article. The urban–rural analyses I report on below were on the basis of this broader definition.
The public-access data of the National Health Interview Survey from 1997 through 2001 (but not 2002) categorize participants’ geographic location as nonmetropolitan area (any area with less than 250000 population) or 1 of 6 types of metropolitan area (based on area population size). The prevalence of significant psychological distress was higher in the nonmetropolitan areas than in the metropolitan areas (3.9% vs 3.0%, P<.001). This finding is at variance with past research that showed no urban–rural differences in psychological distress.1,2 Participants with significant psychological distress from nonmetropolitan areas were less likely than their counterparts from metropolitan areas to report any contact with mental health professionals (29.3% vs 33.0%, P=.02), as likely to report that they could not afford mental health care (16.4% vs 16.8%, P=.70), and more likely to report that they could not afford medications (32.1% vs 27.0%, P<.001). These results are consistent with past research3–5 suggesting a larger burden of unmet need for mental health care in rural areas than in urban areas.
References
1. Kessler RC, Berglund PA, Glantz MD, et al. Estimating the prevalence and correlates of serious mental illness in community epidemiological surveys. In: Manderscheid RW, Henderson MJ, eds. Mental Health, United States, 2002. Rockville, Md: US Dept of Health and Human Services; 2004:155–164.
2. Rohrer JE, Borders TF, Blanton J. Rural residence is not a risk factor for frequent mental distress: a behavioral risk factor surveillance survey. BMC Public Health. 2005;5:46. Available at: http://www.biomedcentral.com/1471-2458/5/46. Accessed March 14, 2006.[CrossRef][Medline]
3. Rost K, Fortney J, Fischer E, et al. Use, quality, and outcomes of care for mental health: the rural perspective. Med Care Res Rev. 2002;59:231–265.
4. Holzer CE, Goldsmith HF, Ciarlo JA. Effects of rural–urban county type on the availability of health and mental health care providers. In: Manderscheid RW, Henderson MJ, eds. Mental Health, United States, 1998. Rockville, Md: US Dept of Health and Human Services; 1998:204–213.
5. Singh GK, Siahpush M. Increasing rural–urban gradients in US suicide mortality, 1970–1997. Am J Public Health. 2002;92:1161–1167.
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