Mental He,alth A Report of the Surgeon General DEPARTMENT OF HEALTH AND HUMAN SERVICES U.S. Public Health Service The Center for Mental Health Servides Substance Abuse and Mental Health Services Administration National Institute of Mental Health National Institutes of Health Suggested Citation U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. For sale by the Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 1X250-7954 Message from Donna E. Shalala Secretary of Health and Human Services The United States leads the world in understanding the importance of overall health and well- being to the strength of a Nation and its people. What we are coming to realize is that mental health is absolutely essential to achieving prosperity. According to the landmark "Global Burden of Disease" study, commissioned by the World Health Organization and the World Bank, 4 of the 10 leading causes of disability for persons age 5 and older are mental disorders. Among developed nations, including the United States, major depression is the leading cause of disability. Also near the top of these rankings are manic-depressive illness, schizophrenia, and obsessive-compulsive disorder. Mental disorders also are tragic contributors to mortality, with suicide perennially representing one of the leading preventable causes of death in the United States atid.worldwide. The U.S. Congress declared the 1990s the Decade of the Brain. In this decade we have learned much through research-in basic neuroscience, behavioral science, and genetics-about the complex workings of the brain. Research can help us gain a further understanding of the fundamental mechanisms underlying thought, emotion, and behavior- and an understanding of what goes wrong in the brain in mental illness. It can also lead to better treatments and improved services for our diverse population. Now, with the publication of this first Surgeon General's Report on Mental Health, we are poised to take what we know and to advance the state of mental health in the Nation. We can with great confidence encourage individuals to seek treatment when they find themselves experiencing the signs and symptoms of mental distress. Research has given us effective treatments and service delivery strategies for many mental disorders. An array of safe and potent medications and psychosocial interventions, typically used in combination, allow us to effectively treat most mental disorders. This seminal report provides us with an opportunity to dispel the myths and stigma surrounding mental illness. For too long the fear of mental illness has been profoundly destructive to people's lives. In fact mental illnesses are just as real as other illnesses, and they are like other illnesses in most ways. Yet fear and stigma persist, resulting in lost opportunities for individuals to seek treatment and improve or recover. In this Administration, a persistent, courageous advocate of affordable, quality mental health services for all Americans is Mrs. Tipper Gore, wife of the Vice President. We salute her for her historic leadership and for her enthusiastic support of the initiative by the Surgeon General, Dr. David Satcher, to issue this groundbreaking Report on Mental Health. The 1999 White House Conference on Mental Health called for a national antistigma campaign. The Surgeon General issued a Call to Action on Suicide Prevention in 1999 as well. This Surgeon General's Report on Mental Health takes the next step in advancing the important notion that mental health is fundamental health. Foreword Since the turn of this century, thanks in large measure to research-based public health innovations, the lifespan of the average American has nearly doubled. Today, our Nation's physical health-as a whole-has never been better. Moreover, illnesses of the body, once shrouded in fear-such as cancer, epilepsy, and HIV/AIDS to name just a few -increasingly are seen as treatable, survivable, even curable ailments. Yet, despite unprecedented knowledge gained in just the past three decades about the brain and human behavior, mental health is often an afterthought and illnesses of the mind remain shrouded in fear and misunderstanding. This Report of the Surgeon General on Mental Health is the product, of an invigorating collaboration between two Federal agencies. The Substance Abuse and Men&Health Services Administration (SAMHSA), which provides national leadership and funding to the states and many professional and citizen organizations that are striving to improve the availability, accessibility, and quality of mental health services, was assigned lead responsibility for coordinating the development of the report. The National Institutes of Health (NM), which supports and conducts research on mental illness and mental health through its National Institute of Mental Health (NIMH), was pleased to be a partner in this effort. The agencies we respectively head were able to rely on the enthusiastic participation of hundreds of people who played a role in researching, writing, reviewing, and disseminating this report. We wish to express our appreciation and that of a mental health constituency, millions of Americans strong, to Surgeon General David Satcher, M.D., Ph.D., for inviting us to participate in this landmark report. The year 1999 witnessed the first White House Conference on Mental Health and the first Secretarial Initiative on Mental Health prepared under the aegis of the Department of Health and Human Services. These activities set an optimistic tone for progress that will be realized in the years ahead. Looking ahead, we take special pride in the remarkable record of accomplishment, in the spheres of both science and services, to which our agencies have contributed over past decades. With the impetus that the Surgeon General's report provides, we intend to expand that record of accomplishment. This report recognizes the inextricably intertwined relationship between our mental health and our physical health and well-being. The report emphasizes that mental health and mental illnesses are important concerns at all ages. Accordingly, we will continue to attend to needs that occur across the lifespan, from the youngest child to the oldest among us. The report lays down a challenge to the Nation- to our communities, our health and social service agencies, our policymakers, employers, and citizens-to take action. SAMHSA and NIH look forward to continuing our collaboration to generate needed knowledge about the brain and behavior and to translate that knowledge to the service systems, providers, and citizens. Nelba Chavez, Ph.D. Steven E. Hyman, M.D. Administrator Director Substance Abuse and Mental Health National Institute of Mental Health Services Administration for The National Institutes of Health Bernard S. Arons, M.D. Director Center for Mental Health Services Preface from the Surgeon C&era/ U.S. Public Health Service The past century has witnessed extraordinary progress in our improvement of the public health through medical science and ambitious, often innovative, approaches to health care services. Previous Surgeons General reports have saluted our gains while continuing to set ever higher benchmarks for the public health. Through much of this era of great challenge and greater achievement, however, concerns regarding mental illness and mental health too often were relegated to the rear of our national consciousness. Tragic and devastating disorders such as schizophrenia, depression and bipolar disorder, Alzheimer's disease, the mental and behavioral disorders suffered by children, and a range of other mental disorders affect nearly one in five Americans in any year, yet continue too frequently to be spoken of in whispers and shame. Fortunately, leaders in the mental health field-fiercely dedicated advocates, scientists, government officials, and consumers-have been insistent that mental health flow in the mainstream of health. I agree and issue this report in that spirit. This report makes evident that the neuroscience of mental health-a term that encompasses studies extending from molecular events to psychological, behavioral, and societal phenomena-has emerged as one of the most exciting arenas of scientific activity and human inquiry. We recognize that the brain is the integrator of thought, emotion, behavior, and health. Indeed, one of the foremost contributions of contemporary mental health research is the extent to which it has mended the destructive split between "mental' and "physical" health. We know more today about how to treat mental illness effectively and appropriately than we know with certainty about how to prevent mental illness and promote mental health. Common sense and respect for our fellow humans tells us that a focus on the positive aspects of mental health demands our immediate attention. Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services. These disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender. A key disparity often hinges on a person's financial status; formidable financial barriers block off needed mental health care from too many people regardless of whether one has health insurance with inadequate mental health benefits, or is one of the 44 million Americans who lack any insurance. We have allowed stigma and a now unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect these barriers. It is time to take them down. Promoting mental health for all Americans will require scientific know-how but, even more importantly, a societal resolve that we will make the needed investment. The investment does not call for massive budgets; rather, it calls for the willingness of each of us to educate ourselves and others about mental health and mental illness, and thus to confront the attitudes, fear, and misunderstanding that remain as barriers before us. It is my intent that this report will usher in a healthy era of mind and body for the Nation. David Satcher, M.D., Ph.D. Surgeon General Acknowledgments Acknowledgments This report was prepared by the Department of Health and Human Services under the direction of the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, in partnership with the National Institute of Mental Health, National Institutes of Health. Nelba Chavez, Ph.D., Administrator, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Harold E. Varmus, M.D., Director, National Institutes of Health, Bethesda, Maryland. Bernard Arons, M.D., Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Steven Hyman, M.D., Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. RADM Thomas Bornemann, Ed.D., Deputy Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Richard Nakamura, Ph.D., Deputy Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. RADM Kenneth Moritsugu, M.D., M.P.H., Deputy Surgeon General, Office of the Surgeon General, Office of the Secretary, Rockville, Maryland. RADM Susan Blumenthal, M.D., M.P.A., Assistant Surgeon General and Senior Science Advisor, Office of the Surgeon General, Office of the Secretary, Rockville, Maryland. Nicole Lurie, M.D., M.S.P.H., Principal Deputy Assistant Secretary for Health, Office of Public Health and Science, Office of the Secretary, Washington, D.C. RADM Arthur Lawrence, Ph.D., Deputy Assistant Secretary for Health, Office of Public Health and Science, Office of the Secretary, Washington, D.C. VirginiaTrotterBetts,M.S.N., J.D.,R.N.,F.A.A.N., Senior Advisor on Nursing and Policy, Office of Public Health and Science, .Office of the Secretary, Washington, D.C. Editors Howard H. Goldman, M.D., Ph.D., Senior Scientific Editor, Professor of Psychiatry, University of Mary- land School of Medicine, Baltimore, Maryland. CAPT Patricia Rye, J.D., M.S.W., Managing Editor, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Paul Sirovatka, M.S., Coordinating Editor, Science Writer, Office of Science Policy and Program Planning, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Section Editors Jeffrey A. Buck, Ph.D., Director, Office of Managed Care, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. CAPT Peter Jensen, M.D., Associate Director for Child and Adolescent Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. . vii Mental Health: A Report of the Surgeon General Judith Katz-Leavy, M.Ed., Senior Policy Analyst, Office of Policy, Planning and Administration, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Planning Board Mary Lou Andersen, Deputy Director, Bureau of Primary Health Care, Health Resources and Services Administration, Bethesda, Maryland. Barry Lebowitz, Ph.D., Chief, Adult and Geriatric Treatment and Preventive Intervention Research Branch. Division of Services and Intervention Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Andrea Baruchin, Ph.D., Chief, Science Policy Branch, Office of Science Policy and Communication, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland. Ronald W. Manderscheid, Ph.D., Chief, Survey and Analysis Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Michael Benjamin, M.P.H., Executive Director, National Council on Family Relations, Minneapolis, Minnesota. Robert Bernstein, Ph.D., Executive Director, Bazelon Center, Washington, D.C. RADM Darrel Regier, M.D., M.P.H., Associate Director, Epidemiology and Health Policy Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Gene Cohen, M.D., Ph.D., Director, George Washington University Center on Aging, Health and Humanities; Director, Washington D.C. Center on Aging, Washington, D.C. Matthew V. Rudorfer, M.D., Associate Director for Treatment Research, Division of Services and Intervention Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Judith Cook, Ph.D., Director, National Research and Training Center on Psychiatric Disability; Professor, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois. Senior Science Writer Margaret Coopey, R.N., Senior Health Policy Analyst, Director, Center for Practice and Technology Assessment, Agency for Health Care Policy and Research, Rockville, Maryland. Miriam Davis, Ph.D., Medical Writer and Consultant, Silver Spring, Maryland. Gail Daniels, Board President, The Federation of Families for Children's Mental Health, Washington, D.C. Science Writers Birgit An der Lan, Ph.D., Science Writer, Bethesda, Maryland. Anne H. Rosenfeld, Special Assistant to the Director, Division of Mental Disorders, Behavioral Research and AIDS, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. . . . Vlll Paolo Del Vecchio, M.S.W., Senior Policy Analyst, Office of Policy, Planning, and Administration, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Michael Eckardt, Ph.D., Senior Science Advisor, Office of Scientific Affairs, National Institute on Alcohol Abuse and Alcoholism National Institutes of Health, Rockville, Maryland. Acknowledgments Mary Jane England, M.D., President, Washington Elliott Heiman, M.D., Chief of Staff of Psychiatry, St. Business Group on Health, Washington, D.C. Mary's Hospital, Tucson, Arizona. Michael English, J.D., Director, Divisionof Knowledge Development and Systems Change, Center for Mental Health Services, Substance Abuse and Mental Health Sewices Administration, Rockville, Maryland. Michael M. Faenza, M.S.S.W., President and Chief Executive Officer, National Mental Health Association, Alexandria, Virginia. Michael Fishman, M.D., Assistant Director, Division of Child. Adolescent and Family Health, Bureau of Maternal and Child Health, Health Resources and Services Administration, Rockville, Maryland. Laurie Flynn, Executive Director, National Alliance for the Mentally Ill, Arlington, Virginia. Larry Fricks, Director, Office of Consumer Relations, Georgia Division of Mental Health, Atlanta, Georgia. Robert Friedman, Ph.D., Director, Research and Training Center for Children's Mental Health, Florida Mental Health Institute, University of South Florida, Tampa. Florida. Laurie Garduque, Ph.D., Senior Program Officer, Program and Community Development, MacArthur Foundation, Chicago, Illinois. John J. Gates, Ph.D., Director of Programs, Collaborative Center for Child Well-being, Decatur, Georgia. Rosa M. Gil, D.S.W., Special Advisor to the Mayor for Health Policy, New York City Mayor's Office of Health Services, New York, New York. Barbara Gill, M.B.A., Executive Director, Dana Alliance for Brain Initiatives, New York, New York. Kevin Hennessy, M.P.P., Ph.D., Health Policy Analyst, Office of the Assistant Secretary for Planning and Evaluation, Office of the Secretary, Washington, D.C. Pablo Hemandez, M.D., Administrator, Wyoming State Commission for Mental Health, Division of Behavioral Health, Evanston, Wyoming. Thomas Horvath, M.D., Chief of Staff, Houston Veterans Affairs Medical Cent&, .Houston, Texas. J. Rock Johnson, J.D., Consultant, Lincoln, Nebraska. Miriam Kelty, Ph.D., Associate Director for Extramural Affairs, National Institute on Aging, National Institutes of Health, Bethesda, Maryland. Lloyd Kolbe, Ph.D., Director, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Jeffrey Lieberman, M.D., Vice Chairman of Research, University of North Carolina, Department of Psychiatry, Chapel Hill, North Carolina. Spero Manson, Ph.D., Director, Division of American Indian and Alaska Native Programs, University of Colorado Health Science Center, Department of Psychiatry, Denver, Colorado. RADM C. Beth Mazzella, R.N., Ph.D., Chief Nurse Officer, Office of the Administrator, Health Resources and Services Administration, Rockville, Maryland. Bruce McEwen, Ph.D., Professor and Head of the Lab for Neuroendocrinology, Rockefeller University, New York, New York. Mary Harper, R.N., Ph.D., Gerontologist, Tuscaloosa, Alabama. ix Mental Health: A Report of the Surgeon General Herbert Pardes, M.D., Vice President for Health Sciences and Dean of the Faculty of Medicine, Columbia University Health Sciences Center, New York, New York. Ruth Ralph, Ph.D., Research Associate, Edmund S. Muskie School of Public Service, University of Southern Maine, Portland, Maine. The Honorable Robert Ray, Former Governor, State of Iowa, Des Moines, Iowa. Corinne Rieder, Ed.D., Executive Director, John A. Hartford Foundation, New York, New York. Mona Rowe, M.C.P., Deputy Director, Office of Science Policy, Analysis, and Communication, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland. Steve Schreiber, M.D., Associate Professor of Neurology, Cell and Neurobiology, University of Southern California School of Medicine, Department of Neurology, Los Angeles, California. Steven A. Schroeder, M.D., President, Robert Wood Johnson Foundation, Princeton, New Jersey. Brent Stanfield, Ph.D., Director, Office of Science Policy and Program Planning, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Stanley Sue, Ph.D., Professor of Psychology and Psychiatry, Director, Asian American Studies Program, Department of Psychology, University of California at Davis, Davis, California. Jeanette Takamura, Ph.D., Assistant Secretary for Aging, Administration on Aging, Washington, D.C. Roy C. Wilson, M.D., Director, Missouri Department of Mental Health, Jefferson City, Missouri. Participants in Developing the Report Norman Abeles, Ph.D., Department of Psychology, Michigan State University, East Lansing, Michigan. Catherine Acuff, Ph.D., Senior Health Policy Analyst, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Laurie Ahem, Director, National Empowerment Center, Inc., Lawrence, Massachusetts. Marguerite Alegria, Ph.D., University of Puerto Rico, Medical Sciences Campus, School of Public Health, San Juan. Puerto Rico. Rene Andersen, M.Ed., Human Resource Association of the Northeast, Holyoke, Massachusetts. Thomas E. Arthur, M.H.A., Coordinator of Consumer Affairs, Maryland Health Partners, Columbia, Maryland. Rosina Becerra, Ph.D., Professor, Department of Social Welfare, Center for Child and Family Policy, University of California at Los Angeles, Los Angeles, California. Comelia Beck, R.N., F.A.A.N., Ph.D., College of Nursing, University of Arkansas for Medical Services, Little Rock, Arkansas. Peter G. Beeson, Ph.D., Administrator, Strategic Management Services, Nebraska Health and Human Services Finance and Support Agency, Lincoln, Nebraska. Leonard Bickman, Ph.D., Professor of Psychology, Center for Mental Health Policy, Institute for Public Policy Studies, Vanderbilt University, Nashville, Tennessee. Robert Boorstin, Senior Advisor to the Secretary of the Treasury, Department of the Treasury, Washington, D.C. X Acknowledgments David Brown, Consultant, Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Barbara J. Bums, Ph.D., Professor of Medical Psychology, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina. Jean Campbell, Ph.D., Research Assistant Professor, Missouri Institute of Mental Health, School of Medicine, University of Missouri-Columbia, St. Louis, Missouri. JosefinaCarbonell, President, Little Havana Activities and Nutrition Centers of Dade County, Inc., Miami, Florida. Elaine Carmen, M.D., Medical Director, Brockton Multi Service Center, Brockton, Massachusetts. H. Westley Clark, M.D., J.D., M.P.H., Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Donald J. Cohen, M.D., Professor of Child and Adolescent Psychiatry, Yale University School of Medicine, New Haven, Connecticut. Judith Cohen, Ph.D., Director, Association for Women's AIDS Risk Education, Corte Madera, California. King Davis, Ph.D., William and Camille Cosby Scholar, Howard University, Washington, D.C. Laura A. DeRiggi, L.S.W ., M.S.W., Clinical Director, Community Behavioral Health, Philadelphia, Pennsylvania. Lisa Dixon, M.D., Associate Professor, Center for Mental Health Services Research; Director of Education, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland. Susan Dubuque, President, Market Strategies, Inc., Richmond, Virginia. Mina K. Dulcan, M.D., Head, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital, Chicago, Illinois. Nellie Fox Edwards, American Association of Retired Persons, Beaverton, Oregon. Lisa T. Eyler-Zorrilla, Ph.D., Post-Doctoral Fellow, Geriatric Psychiatry Clinical Research Center, Department of Psychiatry, University of California-San Diego, La Jolla, California. Theodora Fine, M.A., Special Assistant to the Director, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Dan Fisher, M.D., Ph.D., Executive Director, National Empowerment Center, Inc., Lawrence, Massachusetts. Richard G. Frank, Ph.D., Professor of Health Economics, Department of Health Care Policy, Harvard University, Boston, Massachusetts. Barbara Friesen, Ph.D., Director, Research and Training Center, Family Support and Children's Mental Health, Portland State University, Portland, Oregon. Darrell Gaskin, Ph.D., Research Assistant Professor, Institute for Health Care Research and Policy, Georgetown University Medical Center, Washington, D.C. Mary Jo Gibson, Ph.D., Associate Director of Public Policy Institute, AARP, Washington, D.C. Xi Mental Health: A Report of the Surgeon General Sherry Glied. Ph.D., Associate Professor and Head, Division of Health Policy and Management, Joseph L. Mailman School of Public Health, Columbia University, New York, New York. Margo Goldman, M.D., Policy Director, National Coalition for Patients' Rights, Lexington, .. Massachusetts. Junius Gonzales, M.D., Deputy Chairman, Psychiatry Department, Georgetown University, Washington, D.C. Jack Gorman, M.D., Professor of Psychiatry, Columbia University; Deputy Director, New York State Psychiatric Institute, New York, New York. Barbara Guthrie, Ph.D., R.N., University of Michigan School of Nursing, Ann Arbor, Michigan. Jennifer Gutstein, Research Assistant, Department of Child Psychiatry, Columbia University, New York, New York. Laura Lee Hall, Ph.D., Deputy Director of Policy and Research, National Alliance for the Mentally Ill, Arlington, Virginia. Richard K. Harding, M.D., Medical Director, Psychiatric Services, Richland Springs Hospital, Columbia, South Carolina. Herbert W. Harris, M.D., Ph.D., Chief, Geriatric Pharmacology Programs, Adult and Geriatric Treatment and Preventive Intervention Research Branch, Division of Services and Intervention Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Seth Hassett, M.S.W., Public Health Advisor, Emergency Services and Disaster Relief Branch, Division of Program Development, Special Populations and Projects, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Mario Hemandez, Ph.D., Director, Division of Training, Research, Evaluation and. Demonstrations, Department of Child and Family Studies, Florida Mental Health Institute, Tampa, Florida. Kimberly Hoagwood, Ph.D., Associate Director, Child and Adolescent Research, Natitinal Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Ron Honberg, Director of Legal Affairs, National Alliance for the Mentally Ill, Arlington, Virginia. Teh-wei Hu, Ph.D., Professor'of Health Economics, School of Public Health, University of California-Berkeley, Berkeley, California. Edwin C. Hustead, Senior Consultant, Hay Group, Inc., Washington, D.C. Dilip V. Jeste, M.D., Director, Geriatric Psychiatry Clinical Research Center, University of California at San Diego, Veterans Affairs Medical Center Psychiatry Service, San Diego, California. Ira Katz, M.D., Ph.D., Professor of Psychiatry, Director, Section on Geriatric Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania. Kelly J. Kelleher, M.D., Staunton Professor of Pediatrics, Psychiatry and Health Services, Schools of Medicine and Public Health, Departments of Pediatrics and Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania. Chris Koyanagi, Director of Legislative Policy, Bazelon Center for Mental Health Law, Washington, D.C. Celinda Lake, M.P.S., President and Founder, Lake Snell Perry and Associates, Inc., Washington, D.C. Christopher Langston, Ph.D., Program Officer, John A. Hartford Foundation, New York, New York. xii Acknowledgments John B. Lavigne, Ph.D., Chief Psychologist, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital, Chicago, Illinois. Anthony Lehman, M.D., Director, Center for Mental Health Services Research, University of Maryland School of Medicine, Baltimore, Maryland. Keh-Ming Lin, M.D., M.P.H., Director of Research Center on the Psychobiology of Ethnicity, Professor of Psychiatry, University of California at Los Angeles School of Medicine, Harbor-University of California at Los Angeles Medical Center, Torrance, California. Steven Lopez, Ph.D., Clinical Psychologist, Department of Psychology, University of California at Los Angeles, Los Angeles, California. Ira Lourie, M.D., Partner, Human Service Collaborative, Rockville, Maryland. Francis Lu, M.D., Director of Cultural Competence and Diversity Program, Department of Psychiatry, San Francisco General Hospital, San Francisco, California. Alicia Lucksted, Ph.D., Senior Research Associate, Department of Psychiatry, University of Maryland, Baltimore, Maryland. Bryce Miller, Consultant, National Alliance for the Mentally Ill, Topeka, Kansas. Jeanne Miranda, Ph.D., Associate Professor, Psychiatry Department, Georgetown University, Washington, D.C. Joseph P. Morrissey, Ph.D., Deputy Director, Senior Fellow, Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Patricia J. Mrazek, Ph.D., President, Scientific Director, Prevention Technologies, LLC, Bethesda, Maryland. Denise Nagel, M.D., Executive Director, National Coalition for Patients' Rights, Lexington, Massachusetts. William Narrow, M.D., M.P.H., Senior Advisor for Epidemiology, Office of the Associate Director for Epidemiology and Health Policy Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Cassandra F. Newkirk, M.D., Forensic Psychiatrist and Consultant, Caldwell, New Jersey. Silvia W. Orlate, M.D., Clinical Professor of Psychology, New York Medical College-Vahalla, New York, New York. Trina Osher, M.S.W., Coordinator of Policy and Research, Federation of Families for Children's Mental Health, Alexandria, Virginia. John Petrila, J.D., L.L.M., Chairman and Professor, Department of Mental Health Law and Policy, University of South Florida, Florida Mental Health Institute, Tampa, Florida. RADM Retired William Prescott, M.D., Psychiatrist, Brook Lane Health Service, Hagerstown, Maryland. Juan Ramos, Ph.D., Associate Director for Prevention, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Burton Reifler, M.D., Professor and Chairman, Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, North Carolina. Donald J. Richardson, Ph.D., The Carter Center National Advisory Council; Co-founder and Vice President, National Alliance for Research on Schizophrenia and Depression, Los Angeles, California. Jean Risman, Consumer Researcher, North Berwick, Maine. . . . x111 Mental Health: A Report of the Surgeon General Ariela C. Rod-iguez, Ph.D., L.C.S.W., A.C.S.W., Director, Hlislth dnd Social Services, Little Havana Activities and Nutrition Centers of Dade County, Inc., Miami, Florida. Gloria Rodriguez, Ph.D., President and Chief Executive Officer, Avance Corporation, San Antonio, Texas. Abram Rosenblatt, Ph.D., Research Director, University of California at San Francisco Child Services Research Group, San Francisco, California Agnes E. Rupp, Ph.D., Senior Economist and Chief, Financing and Managed Care Research Program, Services Research and Clinical Epidemiology Branch, Division of Services and Intervention Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. A. John Rush, M.D., Professor of Psychiatry, University of Texas Southwest Medical Center, Department of Psychiatry, Dallas, Texas. David Shaffer, M.D., Professor of Psychiatry and Pediatrics, Director, Division of Child and Adolescent Psychiatry, Columbia University, New York, New York. David Shore, M.D., Associate Director for Clinical Research, Office of the Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Lonnie Snowden, Ph.D., Professor, School of Social Welfare, University of California-Berkeley; Director, Center for Mental Health Services Research, Berkeley, California. George Snicker, Ph.D., Distinguished Research Professor of Psychology, Demer Institute, Adelphi University, Garden City, New York. Michael E. Thase, M.D., Professor of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Jurgen Unutzer, M.D., M.P.H., M.A., Assistant Professor in Residence, Department of Psychiatry, University of California at Los Angeles Neuropsychiatric Institute, Center for Health Services Research, Los Angeles, California. Laura Van Tosh, Consultant, Silver Spring, Maryland. Joan Ellen Zweben, Ph.D., Clinical Professor, Department of Psychiatry, School of Medicine, University of California-San Francisco, Berkeley, California. Other Participants Joan G. Abell, Chief, Information Resources and Inquiries Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Curtis Austin, Director, Office of External Liaison, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Elaine Baldwin, M.Ed., Chief, Public Affairs and Science Reports Branch, Office of Scientific Information, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Leslie Bassett, Program Assistant, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Bonni Bennett, Desktopping Specialist, R.O.W. Sciences, Inc., Rockville, Maryland. Margaret Blasinsky, M.A., Vice President, R.O.W. Sciences, Inc., Rockville, Maryland. Anne B. Carr (formerly Program Assistant, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration), Silver Spring, Maryland. xiv Lemuel B. Clark, M.D., Chief, Community Mental Health Centers Construction Monitoring Branch, Division of Program Development, Special Populations and Projects, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Olavo Da Rocha, Graphic Designer, R.O.W. Sciences, Inc.. Rockville, Maryland. Daria Donaldson, Editor, R.O.W. Sciences, Inc., Rockville, Maryland. Betsy Furin, Program Assistant, Community Mental Health Centers Construction Monitoring Branch, Division of Program Development, Special Populations and Projects, Center for Mental'Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. David Fry, Consultant Writer, Cabin John, Maryland. Charlotte Gordon, Public Affairs Specialist, Office of the Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Beatriz GrarnIey, Public Health Analyst, Primary Care Services Branch, Division of Community Based Programs, HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland. CAPT G. Bryan Jones, Ph.D., Emergency Coordin- ator, Public Health Service Region Three- Philadelphia, Office of Emergency Preparedness, Office of Public Health and Science, Office of the Secretary, Philadelphia, Pennsylvania. Walter Leginski, Ph.D., Branch Chief, Homeless Programs Branch, Division of Knowledge Development and Systems Change, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Ken Lostoski, Senior Graphic Designer, R.O.W. Sciences, Inc., Rockville, Maryland. Acknowledgments Michael Malden, Public Affairs Specialist, Knowledge Exchange Network, Office of External Liaison, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Anne Matthews-Younes, Ed.D., Chief, Special Programs Development Branch, Division of Program Development, Special Populations and Projects, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Kevin McGowan, Contract, Specialist, General Acquisitions Branch, Division of Acquisition Management, Administrative Operations Service, Program Support Center, Rockville, Maryland. Niyati Pandya, M.S., M.Phil., M.L.S., Reference Librarian, R.O.W. Sciences, Inc., Rockville, Maryland. Theodora Radcliffe, Technical Writer/Editor, R.O. W. Sciences, Inc., Rockville, Maryland. Sanjeev Rana, M.S., Research Assistant, R.O.W. Sciences, Inc., Rockville, Maryland. Lisa Robbins, Wordprocessing & Desktopping Coordinator, R.O.W. Sciences, Inc., Rockville, Maryland. Doreen Major Ryan, M.A., Writer/Editor, R.O.W. Sciences, Inc., Rockville, Maryland. Sally Sieracki, M.A., Editor, R.O.W. Sciences, Inc., Rockville, Maryland, Damon Thompson, Director of Communications, Office of Public Health and Science, Office of the Assistant Secretary, Washington, D.C. Robin Toliver, Senior Conference Planner, BL Seamon and Associates, Inc., Lanham, Maryland. Joanna Tyler, Ph.D., Project Director, R.O.W. Sciences, Inc., Rockville, Maryland. xv Mental Health: A Report of the Surgeon General Mark Weber, Associate Administrator, Office of Communications, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Clarissa Wittenberg, Director, Office of Scientific Information, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. Baldwin Wong, Program Analyst, Office of Science Policy, Analysis, and Communication. National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland. Special Thanks To Organizafions The Carter Center, Atlanta, Georgia. The John D. and Catherine T, MacArthur Foundation, Chicago, Illinois. Individuals Virginia Shankle Bales, M.P.H., Deputy Director for Program Management, Centers for Disease Control and Prevention, Atlanta, Georgia. Byron Breedlove, M.A., Senior Writer/Editor, Technical Information and Editorial Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Thomas Bryant, M.D., J.D., Chairman, Non-Profit Management Associates, Inc., Washington, DC. Rosalynn Carter, Vice Chair, The Carter Center, Atlanta, Georgia. RADM J. Jarrett Clinton, M.D., Regional Health Administrator, Office of the Secretary, Atlanta, Georgia. Michael P. Eriksen, Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Christine S. Fralish, M.L.I.S., Chief, Technical Information and Editorial Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Adele Franks, M.D., Prudential Center for Health Services Research (formerly Assistant Director for Science, National Center. for Chronic Disease Prevention and Health Promotio&Centers for Disease Control and Prevention), Atlanta, Georgia. RADM Retired Peter Frommer, M.D., Deputy Director Emeritus, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Gayle Lloyd, M.A., Managing Editor, Surgeon General Reports, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Sandra P. Perlmutter, Executive Director, President's Council on Physical Fitness and Sports, Washington, D.C. NOTICE The editor, the contributors, and the publisher are grateful to the American Psychiatric Association for permission to quote directly from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed. in this work. Descriptive matter is enclosed in quotation marks in the text exactly as it appears in DSM-IV. Tabular matter is modified slightly as to form only in accordance with the publisher's editorial usage. xvi MENTAL HEALTH: A REPORT OF THE SURGEON GENERAL Chapter 1: Introduction and Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ; . .,. . . . . . . . . 1 Overarching Themes .............. ; ........................................ 3 The Science Base of the Report .... .' .......................................... 9 Overvieti of the Report's Chapters ........................................... 11 ChapterConclusions ...................................................... 13 Preparation of the Report ................................................... 23 References ....... . ...................................................... 24 (`haptcr 2: The Fundamentals of Mental Health and Mental Illness . , . . . . . . . . . . . . . . . . . . . . . . 27 The Neuroscience of Mental Health .......................................... 32 Overview of Mental Illness ................................................. 39 Overview of Etiology ...................................................... 49 Overview of Development, Temperament, and Risk Factors ....................... 57 Overview of Prevention .................................................... 62 Overview of Treatment ..................................................... 64 Overview of Mental Health Services .......................................... 73 Overview of Cultural Diversity and Mental Health Services ....................... 80 Overview of Consumer and Family Movements ................................. 92 Overview of Recovery ..................................................... 97 Conclusions ............................................................ 100 References ............................................................. 104 Chapter 3: Children and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Normal Development ..................................................... 124 Overview of Risk Factors and Prevention ..................................... 129 Overview of Mental Disorders in Children .................................... 136 Attention-Deficit/Hyperactivity Disorder ..................................... 142 Depression and Suicide in Children and Adolescents ............................ 150 Other Mental Disorders in Children and Adolescents ............................ 160 Services Interventions .................................................... 168 ServiceDelivery ......................................................... 179 Conclusions ............................................................ 193 References ............................................................. 194 A Report of the Surgeon General Chapter 4: Adults and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . 221 Chapter Overview ........................................................ 225 Anxiety Disorders ........................................................ 233 MoodDisorders ......................................................... 244 Schizophrenia ........................................................... 269 Service Delivery ......................................................... 285 OtherServicesAndSupports ............................................... 289 Conclusions ............................................................. 296 References.. ............................................................ 296 Chapter 5: Older Adults and Mental Health .......................................... 331 Chapter Overview ......................................................... 336 Overview of Mental Disorders in Older Adults ................................. 340 Depression in Older Adults ................................................. 346 Alzheimer's Disease ...................................................... 356 Other Mental Disorders in Older Adults ...................................... 364 ServiceDelivery ......................................................... 370 Other Services and Supports ................................................ 378 Conclusions ............................................................. 381 References .............................................................. 381 Chapter 6: Organizing and Financing Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Overview of the Current Service System ...................................... 405 The Costs of Mental Illness ................................................ 411 Financing and Managing Mental Health Care .................................. 418 Toward Parity in Coverage of ,Mental Health Care .............................. 426 Conclusions ............................................................. 428 Appendix 6-A: Quality and Consumers' Rights ................................. 430 References.. ............................................................ 430 Chapter 7: Confidentiality of Mental Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 Chapter Overview ........................................................ 438 Ethical Issues About Confidentiality ......................................... 438 Values Underlying Confidentiality ........................................... 439 Research on Confidentiality and Mental Health Treatment ........................ 440 Current State of Confidentiality Law ......................................... 441 Federal Confidentiality Laws ............................................... 446 Potential Problems With the Current Legal Framework .......................... 447 Summary.. ............ . ................................................ 448 Conclusions.. ........................................................... 449 References ............................................................... 449 Mental Health Chapter 8: A Vision for the Future ................................................. 45 1 Continue To Build the Science Base ........................................ 453 Overcome Stigma ........................................................ 454 Improve Public Awareness of Effective Treatment ............................. 454 Ensure the Supply of Mental Health Services and Providers ...................... 455 Ensure Delivery of State-of-the-Art Treatments ................................. 455 Tailor Treatment to Age, Gender, Race, and Culttire ............................ 456 Facilitate Entry Into Treatment ............................................. 457 Reduce Financial Barriers to Treatment ...................................... 457 Conclusion ............................................................. 458 References ............................................................. 458 Appendix: Directory of Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 List of Tables and Figures ......................................................... 463 Index ........................................................................ 467 CHAPTER 1 INTRODUCTION AND THEMES Contents Overarching Themes .`. ......................................... 3 ................... Mental Health and Mental Illness: A Public Health Approach .......................... 3 Mental Disorders are Disabling .................................................. 4 Mental Health and Mental Illness: Points on a Continuum ............................. 4 Mind and Body are Inseparable .................................................. 5 TheRootsofStigma.. ......................................................... 6 Separation of Treatment Systems .............................................. 6 Public Attitudes About Mental Illness: 1950s to 1990s ............................. 7 Stigma and Seeking Help for Mental Disorders ................................... 8 Stigma and Paying for Mental Disorder Treatment ................................ 8 Reducing Stigma .......................................................... 8 The Science Base of the Report ..................................................... 9 Reliance on Scientific Evidence ................................................... 9 ResearchMethods ........................................................ 10 LevelsofEvidence ........................................................ 10 Overview of the Report's Chapters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ChapterConclusions ............................................................. 13 Chapter 2: The Fundamentals of Mental Health and Mental Illness ..................... 13 Chapter 3: Children and Mental Health ........................................... 17 Chapter 4: Adults and Mental Health ............................................. 18 Chapter 5: Older Adults and Mental Health ........................................ 19 Chapter 6: Organization and Financing of Mental Health Services ...................... 19 Chapter 7: Confidentiality of Mental Health Information: Ethical, Legal, and Policy Issues . . 20 Chapter 8: A Vision for the Future-Actions for Mental Health in the New Millennium .... 21 PreparationoftheReport ..,..........,........................................... 23 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 CHAPTER 1 INTRODUCTION AND THEMES T his first Surgeon General's Report on Mental Health is issued at the culmination of a half-century [hat has witnessed remarkable advances in the understanding of mental disorders and the brain and in (,llr appreciation of the centrality of mental health to c,\.rrall health and well-being. The report was prepared ;\g;iinst a backdrop of growing awareness in the United States and throughout the world of the immense burden ,,f disability associated with mental illnesses. In the [ Tllitcd States. mental disorders collectively account for 1110rc than 15 percent of the overall burden of disease t'r~rn trll causes and slightly more than the burden ;lssociated with all forms of cancer (Murray & Lopez, 1~16). These data underscore the importance and r~rgcncy of treating and preventing mental disorders and 01` promoting mental health in our society. The report in its entirety provides an up-to-date rcvicw of scientific advances in the study of mental hcalrh and of mental illnesses that affect at least one in I'ivc Americans. Several important conclusions may be drawn from the extensive scientific literature \ummarized in the report. One is that a variety of treatments of well-documented efficacy exist for the ~Irray of clearly defined mental and behavioral disorders that occur across the life span. Every person \hould be encouraged to seekhelp when questions arise about mental health, just as each person is encouraged to seek help when questions arise about health. Research highlighted in the report demonstrates that mental health is a facet of health that evolves throughout the lifetime. Just as each person can do much to promote and maintain overall health regardless Of age, each also can do much to promote and `trengthen mental health at every stage of life. Much remains to be learned about the causes, treatment. and prevention of mental and behavioral disorders. Obstacles that may limit the availability or accessibility of mental health services for some Americans are being dismantled, but disparities persist. Still, thanks to research tid Be experiences of millions of individuals who have a mental disorder, their family members, and other advocates, the Nation has the power today to tear down the most formidable obstacle to future progress in the arena of mental illness and health. That obstacle is stigma. Stigmatization of mental illness is an excuse for inaction and discrimination that is inexcusably outmoded in 1999. As evident in the chapters that follow, we have acquired an immense amount of knowledge that permits us, as a Nation, to respond to the needs of persons with mental illness in a manner that is both effective and respectful. Overarching Themes Mental Health and Mental Illness: A Public Health Approach The Nation's contemporary mental health enterprise, like the broader field of health, is rooted in a population-based public health model. The public health model is characterized by concern for the health of a population in its entirety and by awareness of the linkage between health and the physical and psycho- social environment. Public health focuses not only on traditional areas of diagnosis, treatment, and etiology, but also on epidemiologic surveillance of the health of the population at large, health promotion, disease pre- vention, and access to and evaluation of services (Last & Wallace, 1992). Just as the mainstream of public health takes a broad view of health and illness, this Surgeon General's Report on Mental Health takes a wide-angle lens to both mental health and mental illness. In years Mental Health: A Report of the Surgeon General past, the mental health field often focused principally on mental illness in order to serve individuals who were most severely affected. Only as the field has matured has it begun to respond to intensifying interest and concerns about disease prevention and health pro- motion. Because of the more recent consideration of these topic areas, the body of accumulated knowledge regarding them is not as expansive as that for mental illness. Mental Disorders are Disabling The burden of mental illness on health and productivity in the United States and throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study,' conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide,' ranks second in the burden of disease in established market economies, such as the United States (Table l-l). Mental illness emerged from the Global Burden of Disease study as a surprisingly significant contributor to the burden of disease. The measure of calculating disease burden in this study, called Disability Adjusted Life Years (DALYs), allows comparison of the burden Table l-l. Disease burden by selected illness categories in established market economies, 1990 Percent of Total DALY& All cardiovascular conditions 16.6 All mental illness** 15.4 All malignant diseases (cancer) 15.0 All respiratory conditions 4.8 All alcohol use 4.7 All infectious and parasitic diseases 2.8 All drug use 1.5 *Disability-adjusted life year (DALY) is a measure that expresses years of life lost to premature death and years lived with a disability of specified severity and duration (Murray & Lopez, 1996). **Disease burden associated with "mental illness" includes suicide. * Murray & Lopez, 1996. * The Surgeon General issued a Call to Action on Suicide in 1999, reflecting the public health magnitude of this consequence of mental illness. The Call to Action is summarized in Figure 4-l. of disease across many different disease conditions. DALYs account for lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, ,major depression is equivalent in burden to blindness or paraplegia, whereas active psychosis seen in schizophrenia is equal in disability burden to quadriplegia. By this measure, major depression alone ranked second only to ischemic heart disease in magnitude of disease burden (see Table l-2). Schizophrenia, bipolar disorder, obsessive-compuliive disorder, panic disorder, and post-traumatic stress disorder also contributed significantly to the burden represented by mental illness. Table l-2. Leading sources of disease burden in established market economies, 1990 Total DALYs Percent ' (millions) of Total All causes 98.7 1 lschemic heart disease 8.9 9.0 2 Unipolar major depression 6.7 6.8 3 Cardiovascular disease 5.0 5.0 4 Alcohol use 4.7 4.7 * 5 Road traffic accidents 4.3 4.4 Source: Murray & Lopez, 1996. Mental Health and Mental Illness: Points on a Continuum As will be evident in the pages that follow, "mental health" and "mental illness" are not polar opposites but may be thought of as points on a continuum. Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and contribution to community or society. It is easy to overlook the value of mental health until problems surface. Yet from early childhood until death, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem. These 4 Introduction and Themes .LTc' thr ingredients of each individual's successful ;(,,,tihution to community and society. Americans are inundated with messages about success-in school, in ,1 profession. in parenting, in relationships-without L,ppr~~i~tin~ that successful performance rem On a ~~,und;ltion of mental health. Jlany ingredients of mental health may be ,dcntifiable. but mental health is not easy to define. In (hc \vords of a distinguished leader in the field of ,ncntal health prevention, ". . . built into any definition 01` \\,rllness . . . are overt and covert expressions of \ ;,llles. Because values differ across cultures as well as an,ong subgroups (and indeed individuals) within a ~uI[l~rc. the ideal of a uniformly acceptable definition ,,f the constructs is illusory" (Cowen, 1994). h other \vords. what it means to be mentally healthy is subject 10 ~nnny different interpretations that are rooted in ~~;tluc *judgments that may VW across cultures. The ~hallcnge of defining mental health has stalled the tlcvclopment of programs to foster mental health ( Scckcr. I998), although strides have been made with ~~~llncss programs for older people (Chapter 5). Mc~tclf illness is the term that refers collectively to AI diagnosable mental disorders. Mental disorders are I~caltl~ conditions that are characterized by alterations itI thinking, mood, or behavior (or some.combination ~l~crct~t') associated with distress and/or impaired lunclioning. Alzheimer's disease exemplifies a mental &\ordcr largely marked by alterations in thinking (c+xially forgetting). Depression exemplifies a ~l~nt:il disorder largely marked by alterations in mood. Xltcn[ion-deficit/hyperactivity disorder exemplifies a ~nt:~l disorder largely marked by alterations in IWhavior (overactivity) and/or thinking (inability to concentrate). Alterations in thinking, mood, or behavior contribute to a host of problems-patient distress, iVaired functioning, or heightened risk of death, pain, clihahilitYV or loss of freedom (American Psychiatric ~-\~~ociation. 1994). This report uses the term "mental health problems" t'0r hiens and symptoms of insufficient intensity or duration to meet the criteria for any mental disorder. .\lnlost everyone has experienced mental health problems in which the distress one feels matches some of the signs and symptoms of mental disorders. Mental health problems may warrant active efforts in health promotion, prevention, and treatment. Bereavement symptoms in older adults offer a case in point. Bereavement symptoms of less than 2 months' duration do not qualify as a mental disorder, according to professional manuals for diagnosis (American Psychiatric Association, 1994). Nevertheless, bereavement symptoms can be debilitating if they are left unattended. They place older people at risk for depression, which, in turn, is linked to death from suicide, heart attack, or other causes (Zisook & Shuchter, 1991,1993; Frasufe-Smithet al., 1993,1995; Conwell, 1996). Much can be done-through formal treatment or through support group participation-to ameliorate the symptoms and to avert the consequences of bereavement. In this case, early intervention is needed to address a mental health problem before it becomes a potentially life-threatening disorder. Mind and Body are Inseparable Considering health and illness as points along a continuum helps one appreciate that neither state exists in pure isolation from the other. In another but related context, everyday language tends to encourage a misperception that "mental health" or "mental illness" is unrelated to "physical health" or "physical illness." In fact, the two are inseparable. Seventeenth-century philosopher Rene Descartes conceptualized the distinction between the mind and the body. He viewed the "mind" as completely separable from the "body" (or "matter" in general). The mind (and spirit) was seen as the concern of organized religion, whereas the body was seen as the concern of physicians (Eisendrath & Feder, in press). This partitioning ushered in a separation between so-called "mental" and "physical" health, despite advances in the 20th century that proved the interrelationships between mental and physical health (Cohen & Herbert, 1996; Baum & Posluszny, 1999). Although "mind" is a broad term that has had many different meanings over the centuries, today it refers to the totality of mental functions related to thinking, mood, and purposive behavior. The mind is generally 5 Mental Health: A Report of the Surgeon General seen as deriving from activities within the brain but displaying emergent properties, such as consciousness (Fischbach, 1992; Gazzaniga et al., 1998). One reason the public continues to this day to emphasize the difference between mental and physical health is embedded in language. Common parlance continues to use the term "physical" to distinguish some forms of health and illness from "mental" health and illness. People continue to see mental and physical as separate functions when, in fact, mental functions (e.g., memory) are physical as well (American Psychiatric Association, 1994). Mental functions are carried out by the brain. Likewise, mental disorders are reflected in physical changes in the brain (Kandel, 1998). Physical changes in the brain often trigger physical changes in other parts of the body too. The racing heart, dry mouth, and sweaty palms that accompany a terrifying nightmare are orchestrated by the brain. A nightmare is a mental state associated with alterations of brain chemistry that, in turn, provoke unmistakable changes elsewhere in the body. Instead of dividing physical from mental health, the more appropriate and neutral distinction is between "mental" and "somatic" health. Somatic is a medical term that derives from the Greek word soma for the body. Mental health refers to the ' successful performance of mental functions in terms of thought, mood, and behavior. Mental disorders are those health conditions in which alterations in mental functions are paramount. Somatic conditions are those in which alterations in nonmental functions predominate. While the brain carries out all mental functions, it also carries out some somatic functions, such as movement, touch, and balance. That is why not all brain diseases are mental disorders. For example, a stroke causes a lesion in the brain that may produce disturbances of movement, such as paralysis of limbs. When such symptoms predominate in a patient, the stroke .is considered a somatic condition. But when a stroke mainly produces alterations of thought, mood, or behavior, it is considered a mental condition (e.g., dementia). The point is that a brain disease can be seen as a mental disorder or a somatic disorder depending on the functions it perturbs. The Roots of Stigma Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, ,socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Penn & Martin, 1998; Corrigan & Penn, 1999). It reduces patients' access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its most overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society. Explanations for stigma stem, in part, from the misguided split between mind and body first proposed by Descartes. Another source of stigma lies in the 19th- century separation of the mental health treatment system in the United States from the mainstream of health. These historical influences exert an often immediate influence on perceptions and behaviors in the modem world. Separation of Treatment Systems In colonial times in the United States, people with mental illness were described as "lunaticks" and were largely cared for by families. There was no concerted effort to treat mental illness until urbanization in the early 19th century created a societal problem that previously had been relegated to families scattered among small rural communities. Social policy assumed the form of isolated asylums where persons with mental illness were administered the reigning treatments of the era. By the late 19th century, mental illness was thought to grow "out of a violation of those physical, mental and moral laws which, properly understood and obeyed, result not only in the highest development of the race, but the highest type of civilization" (cited in Grob, 1983). Throughout the history of institutionalization in asylums (later renamed mental hospitals), reformers strove to improve treatment and curtail abuse. Several waves of reform culminated in 6 Introduction and Themes [he deinstitutionalization movement that began in the I 950s with the goal of shifting patients and care to the community. public Affifudes About Mental /ihess: 1950s to 1990s Sationally representative surveys have tracked public attitudes about mental illness since the 1950s (StU, 195:. 1955; Gurin et al., 1960; Veroff et al., 1981). To pcrlnit comparisons over time, several surveys of the 1 970s and the 1990s phrased questions exactly as they had been asked in the 1950s (Swindle et al., 1997). ln the 195Os, the public viewed mental illness as a ,tigInatized condition and displayed an unscientific understanding of mental illness. Survey respdndents typically were nbt able to identify individuals as "mentally ill" when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of be- havior-namely psychosis-as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981). By 1996, a modem survey revealed that Americans had achieved greater scientific understanding of mental illness. But the increases in knowledge did not defuse social stigma (Phelan et al., 1997). The public learned to define mental illness and to distinguish it from ordinary worry and unhappiness. It expanded its definition of mental illness to encompass anxiety, depression, and other mental disorders. The public attributed mental illness to a mix of biological abnormalities and vulnerabilities to social and phychological stress (Link et al., in press). Yet, in comparison with the 195Os, the public's perception of mental illness more frequently incorporated violent behavior (Phelan et al., 1997). This was primarily true among those who defined mental illness to include psychosis (a view held by about one-third of the entire sample). Thirty-one percent of this group mentioned violence in its descriptions of mental illness, in comparison with 13 percent in the 1950s. In other words, the perception of people with psychosis as being dangerous is stronger today than in the past (Phelan et al., 1997). The 1996 survey also probed how perceptions of those with mental illness varied by diagnosis. The public was more likely to consider an individual with schizophrenia as having mental illness than an individual with depression. All of them were distinguished reasonably well from a worried and unhappy individual who did not meet professional criteria for a mental disor&r. The desire for social distance was consistent with this hierarchy (Link et al., in press). Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past (Phelan et al., 1997). This finding begs yet another question: Are people with mental disorders truly more violent? Research supports some public concerns, but the overall likelihood of violence is low. The greatest risk of violence is from those who have dual diagnoses, i.e., individuals who have a mental disorder as well as a substance abuse disorder (Swanson, 1994; Eronen et al., 1998; Steadman et al., 1998). There is a small elevation in risk of violence from individuals with severe mental disorders (e.g., psychosis), especially if they are noncompliant with their medication (Eronen et al., 1998; Swartz et al., 1998). Yet the risk of violence is much less for a stranger than for a family member or person who is known to the person with mental illness (Eronen et al., 1998). Infact, there is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder. Because the average person is ill-equipped to judge whether someone who is behaving erratically has any of these disorders, alone or in combination, the natural tendency is to be wary. Yet, to put this all in perspective, the overall contribution of mental disorders to the total level of violence in society is exceptionally small (Swanson, 1994). 7 Mental Health: A Report of the Surgeon General Because most people should have little reason to fear violence from those with mental illness, even in its most severe forms, why is fear of violence so entrenched? Most speculations focus on media coverage anddeinstitutionalization (Phelan et al., 1997; Heginbotham, 1998). One series of surveys found that selective media reporting reinforced the public's stereotypes linking violence and mental illness and encouraged people to distance themselves from those with mental disorders (Angermeyer & Matschinger, 1996). And yet, deinstitutionalization made this distancing impossible over the 40 years as the population of state and county mental hospitals- was reduced from a high of about 560,000 in 1955 to well below 100,000 by the 1990s (Bachrach, 1996). Some advocates of deinstitutionalization expected stigma to be reduced with community care and commonplace exposure. Stigma might have been greater today had not public education resulted in a more scientific understanding of mental illness. Stigma and Seeking Help for Mental Disorders Nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). Stigma surrounding.the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment (Sussman et al., 1987; Cooper-Patrick et al., 1997). Concern about stigma appears to be heightened in rural areas in relation to larger towns or cities (Hoyt et al., 1997). Stigma also disproportionately affects certain age groups, as explained in the chapters on children and older people. Stigma and Paying for Mental Disorder Treatment Another manifestation of stigma is reflected in the public's reluctance to pay for mental health services. Public willingness to pay for mental health treatment, particularly through insurance premiums or taxes, has been assessed largely through public opinion polls. Members of the public report a greater willingness to pay for insurance coverage for'individuals with severe mental disorders, such as schizophrenia and depression, rather than for less severe conditions such as worry and unhappiness (Hanson, 1998). While the public generally appears to support paying for treatment, its support diminishes upon the realization that higher taxes or premiums would be necessary (Hanson, 1998). In the lexicon of survey research, the willingness to pay for mental illness treatment services is considered to be "soft." The public generally ranks insurance coverage for mental disorders below that for somatic disorders (Hanson, 1998). 8 The surveys cited above concerning evolving public attitudes about mental illness also monitored how people would cope with, and seek treatment for, mental illness if they became symptomatic. (The term "nervous breakdown" was used in lieu of the term "mental illness" in the 1996 survey to allow for comparisons with the surveys in the 1950s and 1970s.) The 1996 survey found that people were likelier than in the past to approach mental illness by coping with, rather than by avoiding, the problem. They also were more likely now to want informal social supports (e.g., self-help groups). Those who now sought form-d support increasingly preferred counselors, psychologists, and social workers (Swindle et al., 1997). Reducing Stigma There is likely no simple or single panacea to eliminate the stigma associated with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved. Knowledge of mental illness appears by itself insufficient to dispel stigma (Phelan et al., 1997). Broader knowledge may be warranted, especially to redress public fears (Penn & Martin, 1998). Research is beginning to demonstrate that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Overall approaches to stigma reduction involve programs of advocacy, public education, and contact with persons with mental illness through schools and other societal institutions (Conigan & Penn, 1999). Another way to eliminate stigma is to find causes 3nd effective treatments for mental disorders (Jones, ,998). History suggests this to be true. Neurosyphilis and petlagra are illustrative of mental disorders for \vhich stigma has receded. In the early part of this srntury. about 20 percent of those admitted to mental ho5Pitats had "general paresis," later identified as tcniary syphilis (Grob, 1994). This advanced stage of ,yPhitis occurs when the bacterium invades the brain rind causes neurological deterioration (including P\ychosis). paralysis, and death. The discoveries of an infectious etiology and of penicillin led to the virtual elimination of neurosyphilis. Similarly, when pellagra \v;ts traced to a nutrient deficiency, and nutritional ,upplementation with niacin was introduced, the cnndition was eventually eradicated in the developed \vorld. Pellagra's victims with delirium had been placed in mental hospitals early in the 20th century before its etiology was clarified. Although no one has documented directly the reduction of public stigma reward these conditions over the early and later parts of this century, disease eradication through widespread acceptance of treatment (and its cost) offers indirect Proof. Ironically, these examples also illustrate a more unsettling consequence: that the mental health field was :ttlvcrsely affected when causes and treatments were identified. As advances were achieved, each condition \~;Is transferred from the mental health field to another medical specialty (Grob, 1991). For instance, dominion over syphilis was moved to dermatology, internal medicine, and neurology upon advances in etiology and treatment. Dominion over hormone-related mental disorders was moved to endocrinology under similar circumstances. The consequence of this transformation, according to historian Gerald Grob, is that the mental health field became over the years the repository for mental disorders whose etiology was unknown. This left the mental health field "vulnerable to accusations by their medical brethren that psychiatry was not part of medicine, and that psychiatric practice rested on \uPerstition and myth" (Grob, 1991). These historical examples signify that stigma dissipates for individual disorders once advances Introduction and Themes render them less disabling, infectious, or disfiguring. Yet the stigma surrounding other mental disorders not only persists but may be inadvertently reinforced by leaving to mental health care only those behavioral conditions without known causes or cures. To point this out is not intended to imply that advances in mental health should be halted; rather, advances should be nurtured and heralded. The purpose here is to explain some of the historical origins of the chasm between the health and mental health fields. Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises ti, be an effective antidote. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate. Still, fresh approaches to disseminate research information and, thus, to counter stigma need to be developed and evaluated. Social science research has much to contribute to the development and evaluation of anti-stigma programs (Corrigan & Penn, 1999). As stigma abates, a transformation in public attitudes should occur. People should become eager to seek care. They should become more willing to absorb its cost. And, most importantly, they should become far more receptive to the messages that are the subtext of this report: mental health and mental illness are part of the mainstream of health, and they are a concern for all people. The Science Base of the Report Reliance on Scientific Evidence The statements and conclusions throughout this report are documented by reference to studies published in the scientific literature. For the most part, this report cites studies of empirical-rather than theoretical-research, peer-reviewed journal articles including reviews that integrate findings fromnumerous studies, and books by recognized experts. When a study has been accepted for publication but the publication has not yet appeared, owing to the delay between acceptance and final publication, the study is referred to as "in press." The 9 Mental Health: A Report of the Surgeon General report refers, on occasion, to unpublished research by means of reference to a presentation at a professional meeting or to a "personal communication" from the researcher, a practice that also is used sparingly in professional journals. These personal references are to acknowledged experts whose research is in progress. Research Methods Quality research rests on accepted methods of testing hypotheses. Two of the more common research methods used in the mental health field are experimental research and correlational research. Experimental research is the preferred method for assessing causation but may be too difficult or too expensive to conduct. Experimental research strives to discover cause andeffect relationships, such as whether a new drug is effective for treating a mental disorder. In an experimental study, the investigator deliberately introduces an intervention to. determine its conse- quences (i.e., the drug's efficacy). The investigator sets up an experiment comparing the effects of giving the new drug to one group of people, the experimental group, while giving a placebo (an inert pill) to another group, the so-called control group. The incorporation of a control group rules out the possibility that something other than the experimental treatment (i.e., the new drug) produces the results. The difference in outcome between the experimental and control group-which, in this case, may be the reduction or elimination of the symptoms of the disorder-then can be causally attributed to the drug. Similarly, in an experimental study of a psychological treatment, the experimental group is given a new type of psychotherapy, while the control or comparison group receives either no psychotherapy or a different form of psychotherapy. With both pharmacological and psychological studies, the best way to assign study participants, called subjects, either to the treatment or the control (or comparison) group is by assigning them randomly to different treatment groups. Randomization reduces bias in the results. An experimental study in humans with randomization is called a randomized controlled trial. Correlational research is employed when experimental research is logistically, ethically, or financially impossible. Instead of deliberately introducing an intervention, researchers observe relationships to uncover whether two factors are associated, or correlated. Studying the relationship between stress and depression is illustrative. It would be unthinkable to introduce seriously stressful events to see if they cause depression. A correlational study in this case would compare a group of people already experiencing high levels of stress with another group experiencing low levels of stress to determine whether the high-stress group is more likely to develop depression. If this happens, then the results would indicate that high levels of stress are associated with depression. The limitation of this type of study is that it only can be used to establish associations, not cause and effect relationships. (The positive relationship between stress and depression is discussed most thoroughly in Chapter 4.) Controlled studies-that is, studies with control or comparison groups-are considered superior to uncontrolled studies. But not every question in mental health can be studied with a control or comparison group. Findings from an uncontrolled study may be better than no information at all. An uncontrolled study also may be beneficial in generating hypotheses or in testing the feasibility of an intervention. The results presumably would lead to a controlled study. In short, uncontrolled studies offer a good starting point but are never conclusive by themselves. levels of Evidence In science, no single study by itself, however well designed, is generally considered sufficient to establish causation. The findings need to be replicated by other investigators to, gain widespread acceptance by the scientific community. The strength of the evidence amassed for any scientific fact or conclusion is referred to as "the level of evidence." The level of evidence, for example, to justify the entry of a new drug into the marketplace has to be substantial enough to meet with approval by the U.S. Food and Drug Administration (FDA). According to U.S. drug law, a new drug's safety and efficacy must be established through controlled clinical trials 10 Introduction and Themes ;,,uducted by the drug's manufacturer or sponsor , l~D.4. 1998). The FDA's decision to approve a drug rcpr,=sents the culmination of a lengthy, research- ,utcusive process of drug development, which often consumes years of animal testing followed by human clinical trials (DiMasi & Lasagna, 1995). The FDA requires three phases of clinical trials3 before a new drug can be approved for marketing (FDA, 1998). With psychotherapy, the level of evidence similarly ,llust be high. Although there are no formal Federal laLvs governing which psychotherapies can be iutroduced into practice, professional groups and cspees in the field strive to assess the level of evidence ill 3 giveu area through task forces, review articles, and otbcr methods for evaluating the body of published \tudies on a topic. This Surgeon General's report is replete with references to such evaluations. One of the most prominent series of evaluations was set in motion hy a group within the American Psychological :\ssociation (APA), one of the main professional organizations of psychologists. Beginning in the mid- I WOs. the APA's Division of Clinical Psychology convened task forces with the objective of establishing which psychotherapies were of proven efficacy. To guide their evaluation, the first task force created a set ol`critcria that also was used or adapted by subsequent Iask forces. The first task force actually developed two ~1s of criteria: the first, and more rigorous, set of ukria was for Well-Established Treatments, while the ()[kr set was for Probably Eficacious Treatments t Chumbless et al., 1996). For a psychotherapy to be ~11 established, at least two experiments with group designs or similar types of studies must have been published to demonstrate efficacy. Chapters 3 through 5 of this report describe the findings of the task forces in relation to psychotherapies for children, adults, and older adults. Some types of psychotherapies that do not meet the criteria might be effective but may not have been studied sufficiently. ' The first phase is to establish safety (Phase I), while the latter two phases establish efficacy through small and then large-scale randomized controlled clinical trials (Phases II and III) (FDA, 1998). Another way of evaluating a collection of studies is through a formal statistical technique called a meta- analysis. A meta-analysis is a way of combining results from multiple studies. Its goal is to determine the size and consistency of the "effect" of a particular treatment or other intervention observed across the studies. The statistical technique makes. the results of different studies comparable so that an overall "effect size" for the treatment can be identified. A meta-analysis determines if there is consistent evidence of a statistically significant effect of a specified treatment and estimates the size of the effect, according to widely accepted standards for a small, medium, or large effect. Overview of the Report's Chapters The preceding sections have addressed overarching themes in the body of the report. This section provides a brief overview of the entire report, including a description of its general orientation and a summary of key conclusions drawn from each chapter. Chapter 2 begins with an overview of research under way today that is focused on the brain and behavior in mental health and mental illness. It explains how newer approaches to neuroscience are mending the mind-body split, which for so long has been a stumbling block to understanding the relationship of the brain to behavior, thought, and emotion. Modem integrative neuroscience offers a means of linking research on broad "systems-level" aspects of brain function with the remarkably detailed tools and findings of molecular genetics. There follows an overview of mental illness that highlights topics including symptoms, diagnosis, epidemiology (i.e., research having to do with the distribution and determinants of mental disorders in population groups), and cost, all of which are discussed in the context of specific disorders throughout the report. The section on etiology reviews research that is seeking to define, with ever greater precision, the causes of mental illnesses. As will be seen, etiology research must examine fundamental biological and behavioral processes, as well as a necessarily broad array of life events. No less than research on normal healthy development, etiological research underscores the inextricability of 11 Mental Health: A Report of the Surgeon General nature and nurture, or biological and psychosocial influences, in mental illness. The section on development of temperament reveals how mental health research has attempted over much of the past century to understand how biological, psychological, and sociocultural factors meld in health as well as illness. The chapter then reviews research approaches to the prevention and treatment of mental disorders and provides an overview of mental health services and their delivery. Final sections cover the growing influence on the mental health field of cultural diversity, the importance of consumerism, and new optimism about recovery from mental illness. Chapters 3,4, and 5 capture the breadth, depth, and vibrancy of the mental health field. The chapters probe mental health and, mental illness in children and adolescents, in adulthood (i.e., in persons up to ages 55 to 65), and in older adults, respectively. This life span approach reflects awareness that-mental health, and the brain and behavioral disorders that impinge upon it, are dynamic, ever-changing phenomena that, at any given moment, reflect the sum total of every person's genetic inheritance and life experiences. The brain is extraordinarily "plastic," or malleable. It interacts with and responds-both in its function and in its very structure-to multiple influences continuously, across every stage of life. Variability in expression of mental health and mental illness over the life span can be very subtle or very pronounced. As an example, the symptoms of separation anxiety are normal in early childhood but are signs of distress in later childhood and beyond. It is all too common for people to appreciate the impact of developmental processes in children yet not to extend that conceptual understanding to older people. In fact, older people continue to develop and change. Different stages of life are associated with distinct forms of mental and behavioral disorders and with distinctive capacities for mental health. With rare exceptions, few persons are destined to a life marked by unremitting, acute mental illness. The most severe, persistent forms of mental illness tend to be amenable to treatment, even when recurrent and episodic. As conditions wax and wane, opportunities exist for interventions. The goal of an intervention at any given time may vary. The focus may be. on recovery, prevention of recurrence, or the acquisition of knowledge or skills that permit more effective management of an illness. Chapters 3 through 5 cover a uniform list of topics most relevant to each age cluster. Topics include mental health; prevention, diagnosis, and treatment of mental illness; service delivery; and other services and supports. It would be impractical for a report of this type to attempt to address every domain of mental health and mental illness; therefore, this report casts a spotlight on selected topics in each of Chapters 3 through 5. The various disorders featured in Depth in a given chapter were selected on the basis of their prevalence and the clinical, societal, and economic burden associated with each. To the extent that data permit, the report takes note of how gender and culture, in addition to age, influence the diagnosis, course, and treatment of mental illness. The chapters also note the changing role of consumers and families, with attention to informal support services (i.e., unpaid services) with which patients are so comfortable (Phelan et al., 1997) and upon which they depend for information. Patients and families welcome a proliferating array of support services-such as self-help programs, family self-help, crisis services, and advocacy-that help them cope with the isolation, family disruption, and possible loss of employment and housing that may accompany mental disorders. Support services can help dissipate stigma and guide patients into formal care as well. Although the chapters that address stages of development afford a sense of the breadth of issues pertinent to mental health and illness, the report is not exhaustive. The neglect of any given disorder, population, or topic should not be construed as signifying a lack of importance. Chapter 6 discusses the organization and financing of mental health services. The first section provides an overview of the current system of mental health services, describing where people get care and how they use services. The chapter then presents information on the costs of care and trends in spending. Only within recent decades have the dynamics of 12 Introduction and Themes ,I,4ur3nce financing become a significant issue in the I,,ental health field; these are discussed, as is the advent ,,t managed care. The chapter addresses both positive .,,,d adverse effects of managed care on access and qudlity and describes efforts to guard against untoward Lon\cquences of aggressive cost-containment policies. The final section documents some of the inequities bettVeen general health care and mental health care and &,cribes efforts to correct them through legislative regulation and financing changes. The confidentiality of all health care information has emerged as a core issue in recent years, as concerns regarding the accessibility of health care information & its uses have risen. As Chapter 7 illustrates, privacy c(Juccrns are particularly keenly felt in the `mental tlcdth field, beginning with the importance of an ;l\surance of confidentiality in individual decisions to \cck mental health treatment. The chapter reviews the kyal I'rumework governing confidentiality and potential prohlcms with that framework, and policy issues that must be addressed by those concerned with the ~oul`idcntiality of mental health and substance abuse iril~ormation. Chapter 8 concludes, on the basis of the extensive literature that the Surgeon General's reportreviews and 4umm;lrizes, that the efficacy of mentul health treatment is well-documented. Moreover, there exists :I range of treatments from which people may choose a t';lrticular approach to suit their needs and preferences. 1i:~d on this finding, the report's principal recommendation to the American people is to seek help if YOU have a mental health problem or think you IlaVe SYWtoms of mental illness. The chapter explores TPofiunities to overcome barriers to implementing the recommendation and to have seeking help lead to dfective treatment. Chapter Conclusions Chapter 2: The Fundamentals of Mental Health and Mental Illness The past 25 years have been marked by several discrete, defining trends in the mental health field. These have included: 1. The extraordinary pace and productivity of scientific research on the brain and behavior; 2. The introduction of a range of effective treatments for most mental disorders; 3. A dramatic transformation of our society's approaches to the organization and financing of mental health care; and 4. The emergence of powerful consumer and family movements. Scientific Research. The brain has emerged as the central focus for studies of mental health and mental illness. New scientific disciplines, technologies, and insights have begun to weav'e a seamless picture of the way in which the brain mediates the influence of biological, psychological, and social factors on human thought, behavior, and emotion in health and in illness. Molecular and cellular biology and molecular genetics, which are complemented by sophisticated cognitive and behavioral sciences, are preeminent research disciplines in the contemporary neuroscience of mental health. These disciplines are affording unprecedented opportunities for "bottom-up" studies of the brain. This term refers to research that is examining the workings of the brain at the most fundamental levels. Studies focus, for example, on the complex neurochemical activity that occurs within individual nerve cells, or neurons, to process information; on the properties and roles of proteins that are expressed, or produced, by a person's genes; and on the interaction of genes with diverse environmental influences. All of these activities now are understood, with increasing clarity, to underlie learning, memory, the experience of emotion, and, when these processes go awry, the occurrence of mental illness or a mental health problem. Equally important to the mental health field is "top- down" research; here, as the term suggests, the aim is to understand the broader behavioral context of the brain's cellular and molecular activity and to learn how individual neurons work together in well-delineated neural circuits to perform mental functions. ESfective Treatments. As information accumulates about the basic workings of the brain, it is the task of translational research to transfer new knowledge into clinically relevant questions and targets of research 13 Mental Health: A Report of the Surgeon General opportunity-to discover, for example, what specific properties of a neural circuit might make it receptive to safer, more effective medications. To elaborate on this example, theories derived from knowledge about basic brain mechanisms are being wedded more closely to brain imaging tools such as functional Magnetic Resonance Imaging (MRI) that can observe actual brain activity. Such a collaboration would permit investi- gators to monitor the specific protein molecules intended as the "targets" of a new medication to treat a mental illness or, indeed, to determine how to optimize the effect on the brain of the learning achieved through psychotherapy. In its entirety, the new "integrative neuroscience" of mental health offers a way to circumvent the antiquated split between the mind and the body that historically has hampered mental health research. It also makes it possible to examine scientifically many of the important psychological and behavioral theories regarding normal development and mental illness that have been developed in years past. The unswerving goal of mental health research is to develop and refine clinical treatments as well as preventive interventions that are based on an understanding of specific mechanisms that can contribute to or lead to illness but also can protect and enhance mental health. Mental health clinical research encompasses studies that involve human participants, conducted, for example, to test the efficacy of a new treatment. A noteworthy feature of contemporary clinical research is the new emphasis being placed on studying the effectiveness of interventions in actual practice settings. Information obtained from such studies increasingly provides the foundation for services research concerned with the cost, cost-effectiveness, and "deliverability" of interventions and the design-including economic considerations-of ser- vice delivery systems. Organization and Financing of Mental Health Care. Another of the defining trends has been the transformation of the mental illness treatment and mental health services landscapes, including increased reliance on primary health care and other human service providers. Today, the U.S. mental health system is multifaceted and complex, comprising the public and private sectors, general health and specialty mental health providers, and social services, housing, criminal justice, and educational agencies. These agencies do not always function in a coordinated manner. Its configuration reflects necessary responses to a broad array of factors including reform movements, financial incentives based on who pays for what kind of services, and advances in care and treatment technology. Although the hybrid system that exists today serves diverse functions well for many people, individuals with the most complex need? and the fewest financial resources often find the system fragmented and difficult to use. A challenge for the Nation in the near- term future is to speed the transfer of new evidence- based treatments and prevention interventions into diverse service delivery settings and systems, while ensuring greater coordination among these settings and systems. Consumer and Family Movements. The emergence of vital consumer and family movements promises to shape the direction and complexion of mental health programs for many years to come. Although divergent in their historical origins and philosophy, organizations representing consumers and family members have promoted important, often overlapping goals and have invigorated the fields of research as well as treatment and service delivery design. Among the principal goals shared by much of the consumer movement are to overcome stigma and prevent discrimination in policies affecting persons with mental illness: to encourage self- help and a focus on recovery from mental illness; and to draw attention to the special needs associated with a particular disorder or disability, as well as by age or gender or by the racial and cultural identity of those who have mental illness. Chapter 2 of the report was written to provide background information that would help persons from outside the mental health field better understand topics addressed in subsequent chapters of the report. Although the chapter is meant to serve as a mental health primer, its depth of discussion supports a range of conclusions: 14 Introduction and Themes , . The multifaceted complexity Of the brain iS fully consistent with the fact that it SUPPOSES all behavior and mental life. Proceeding from an ,chowledgment that all psychological experiences are recorded ultimately in the brain and that all ps~chologicaI phenomena reflect biological processes, the modem neuroscience of mental health offers an enriched understanding of the inseparability of human experience, brain, and mind. 2. .Mental functions, which are disturbed in mental disorders, are mediated by the brain. In the process of transforming human experience into physical events, the brain undergoes changes in its cellular structure and function. 3. Few lesions or physiologic abnormalities define the mental disorders, and for the most part their causes remain unknown. Mental disorders, instead, are defined by signs, symptoms, and functional impairments. J. Diagnoses of mental disorders made using specific criteria are as reliable as those for general medical disorders. 5. About one in five Americans experiences a mental disorder in the course of a year. Approximately 15 percent of all adults who have a mental disorder in one year also experience a co-occurring substance (alcohol or other drug) use disorder, which complicates treatment. 6. A range of treatments of well-documented efficacy exists for most mental disorders. Two broad types of intervention include psychosocial treat- ments -for example, psychotherapy or counseling-and psychopharmacologic treatments; these often are most effective when combined. 7. In the mental health field, progress in developing Preventive interventions has been slow because, for most major mental disorders, there is insufficient understanding about etiology (or causes of illness) andor there is an inability to alter the known etiology of a particular disorder. Still, some successful strategies have emerged in the absence of a full understanding of etiology. 8. About 10 percent of the U.S. adult population use mental health services in the health sector in any year, with another 5 percent seeking such services from social service agencies, schools, or religious or self-help groups. Yet critical gaps exist between those who need service and those who receive service. 9. Gaps also exist between optimally effective treatment and what many individuals receive in actual practice settings. 10. Mental illness and less severe mental health problems must be understood in a social and cultural context, and mental health services must be designed and delivered in a manner that is sensitive to the perspectives and needs of racial and ethnic minorities. 11. The consumer movement has increased the involvement of individuals with mental disorders and their families in mutual support services, consumer-run services, and advocacy. They are powerful agents for changes in service programs and policy. 12. The notion of recovery reflects renewed optimism about the outcomes of mental illness, including that achieved through an individual's own self-care efforts, and the opportunities open to persons with mental illness to participate to the full extent of their interests in the community of their choice. Mental Health and Mental illness Across the Lifespan The Surgeon General's report takes a lifespan ap- proach to its consideration of mental health and mental illness. Three chapters that address, respectively, the periods of childhood and adolescence, adulthood, and later adult life beginning somewhere between ages 55 and 65, capture the contributions of research to the breadth, depth, and vibrancy that characterize all facets of the contemporary mental health field. The disorders featured in depth in Chapters 3, 4, and 5 were selected on the basis of the frequency with which they occur in our society, and the clinical, societal, and economic burden associated with each. To the extent that data permit, the report takes note of how 15 Mental Health: A Report of the Surgeon General gender and culture, in addition to age, influence the diagnosis, course, and treatment of mental illness. The chapters also note the changing role of consumers and families, with attention to informal support services (i.e., unpaid services), with which many consumers are comfortable and upon which they depend for information. Persons with mental illness and, often, their families welcome a proliferating array of support services-such as self-help programs, family self-help, crisis services, and advocacy-that help them cope with the isolation, family disruption, and possible loss of employment and housing that may accompany mental disorders. Support services can help to dissipate stigma and to guide patients into formal care as well. Mental health and mental illness are dynamic, ever- changing phenomena. At any given moment, a person's mental status reflects the sum total of that individual's genetic inheritance and life experiences. The brain interacts with and responds-both in its function and in its very structure- to multiple influences continuously, across every stage of life. At different stages, variability in expression of mental health and mental illness can be very subtle or very pronounced. As an example, the symptoms of separation anxiety are normal in early childhood but are signs of distress in later childhood and beyond. It is all too common for people to appreciate the impact of developmental processes in children, yet not to extend that conceptual understanding to older people. In fact, people continue to develop and change throughout life. Different stages of life are associated with vulnerability to distinct forms of mental and behavioral disorders but also with distinctive capacities for mental health. Even more than is true for adults, children must be seen in the context of their social environments-that is, family and peer group, as well as that of their larger physical and cultural surroundings, Childhood mental health is expressed in this context, as children proceed along the arc of development. A great deal of contemporary research focuses on developmental processes, with the aim of understanding and predicting the forces that will keep children and adolescents mentally healthy and maintain them on course to become mentally healthy adults. Research also focuses on identifying what factors place some at risk for mental illness and, yet again, what protects some children but not others despite exposure to the same risk factors. In addition to studies of normal development and of risk factors, much research focuses on mental disorders in childhood and adolescence and what can be done to prevent or treat these conditions and on the design and operation of service settings best suited to the needs experienced by children. For about one in five Americans, adulthood-a time for achieving productive vocations and for sustaining close relationships at home and in the community-is interrupted by mental illness. Understanding why and how mental disorders occur in adulthood, often with no apparent portents of illness in earlier years, draws heavily on the full panoply of research conducted under the aegis of the mental health field. In years past, the onset, or occurrence, of mental illness in the adult years, was attributed principally to observable phenomena-for example, the burden of stresses associated with career or family, or the inheritance of a disease viewed to run in a particular family. Such explanations now may appear naive at best. Contemporary studies of the brain and behavior are racing to fill in the picture by elucidating specific neurobiological and genetic mechanisms that are the platform upon which a person's life experiences can either strengthen mental health or lead to mental illness. It now is recognized that factors that influence brain development prenatally may set the stage for a vulnerability to illness that may lie dormant throughout childhood and adolescence. Similarly, no single gene has been found to be responsible for any specific mental disorder; rather, variations in multiple genes contribute to a disruption in healthy brain function that, under certain environmental conditions, results in a mental illness. Moreover, it is now recognized that socioeconomic factors affect individuals' vulnerability to mental illness and mental health problems. Certain demographic and economic groups are more likely than others to experience mental health problems and some mental disorders. Vulnerability alone may not be sufficient to cause a mental disorder; rather, the causes of most mental disorders lie in some combination of 16 Introduction and Themes ,,enetic and environmental factors, which may be biological or psychosocial. The fact that many, if not most, peOpk have esperienced mental health problems that mimic or even match some of the symptoms of a diagnosable mental disorder tends, ironically, t0 PrOrIlpt many people t0 underestimate the painful, disabling nature of severe mental illness. In fact, schizophrenia, mood disorders ,uch as major depression and bipolar illness, and anxiety often are devastating conditions. Yet relatively fe\v mental illnesses have an unremitting course mark- ed by the most acute manifestations of illness; rather, for reasons that are not yet understood, the symptoms ;tssociated with mental illness tend to wax and wane. These patterns pose special challenges to the implementation of treatment plans and the design of service systems that are optimally responsive to an individual's needs during every phase of illness. As this report concludes, enormous strides are being made in diagnosis, treatment, and service delivery, placing the productive and creative possibilities of adulthood within the reach of persons who are encumbered by mental disorders. Late adulthood is when changes in health status may become more noticeable and the ability to compensate for decrements may become limited. As the brain ages, a person's capacity for certain mental tasks tends to diminish, even as changes in other mental activities prove to be positive and rewarding. Well into late life, the ability to solve novel problems can be enhanced through training in cognitive skills and problem-solving strategies. The promise of research on mental health Promotion notwithstanding, a substantial minority of older people are disabled, often severely, by mental disorders including Alzheimer's disease, major depression, substance abuse, anxiety, and other conditions. In the United States today, the highest rate of suicide-an all-too-common consequence of unrecognized or inappropriately treated depression-is found in older males. This fact underscores the urgency of ensuring that health care provider training properly emphasizes skills required to differentiate accurately me causes of cognitive, emotional, and behavioral symptoms that may, in some instances, rise to the level of mental disorders, and in other instances be expressions of unmet general medical needs. As the life expectancy of Americans continues to extend, the sheer number-although not necessarily the proportion--of persons experiencing mental disorders of late life will expand, confronting our society with unprecedented challenges in organizing, financing, and delivering effective mental health services for this population. An essential part of the needed societal response will include recognizing and devising innovative ways of support@g the increasingly more prominent role that families are assuming in caring for older, mentally impaired and mentally ill family members. Chapter 3: Children and Mental Health 1. Childhood is characterized by periods of transition and reorganization, making it critical to assess the mental health of children and adolescents in the context of familial, social, and cultural expectations about age-appropriate thoughts, emotions, and behavior. 2. The range of what is considered "normal" is wide; still, children and adolescents can and do develop mental disorders that are more severe than the "ups and downs" in the usual course of development. 3. Approximately one in five children and adolescents experiences the signs and symptoms of a DSM-IV disorder during the course of a year, but only about 5 percent of all children experience what professionals term "extreme functional impair- ment." 4. Mental disorders and mental health problems appear in families of all social classes and of all backgrounds. No one is immune. Yet there are children who are at greatest risk by virtue of a broad array of factors. These include physical problems; intellectual disabilities (retardation); low birth weight; family history of mental and addictive disorders; multigenerational poverty; and caregiver separation or abuse and neglect. 5. Preventive interventions have been shown to be effective in reducing the impact of risk factors for 17 Mental Health: A Report of the Surgeon General mental disorders and improving social and emotional development by providing, for example, educational programs for young children, parent- education programs, and nurse home visits. 6. A range of efficacious psychosocial and pharmacologic treatments exists for many mental disorders in children, including attention- deficit/hyperactive disorder, depression, and the disruptive disorders. 7. Research is under way to demonstrate the effectiveness of most treatments for children in actual practice settings (as opposed to evidence of "efficacy" in controlled research settings), and significant barriers exist to receipt of treatment. 8. Primary care and the schools are major settings for the potential recognition of mental disorders in children and adolescents, yet trained staff are limited, as are options for referral to specialty care. 9. The multiple problems associated with "serious emotional disturbance" in children and adolescents are best addressed with a "systems" approach in which multiple service sectors work in an organized, collaborative way. Research on the effectiveness of systems of care shows positive results for system outcomes and functional outcomes for children; however, the relationship between changes at the system level and clinical outcomes is still unclear. 10. Families have become essential partners in the delivery of mental health services for children and adolescents. 11. Cultural differences exacerbate the general problems of access to appropriate mental health services. Culturally appropriate services have been designed but are not widely available. Chapter 4: Adults and Mental Health 1. As individuals move into adulthood, develop- mental goals focus on productivity and intimacy including pursuit of education, work, leisure, creativity, and personal relationships. Good mental health enables individuals to cope with adversity while pursuing these goals. 2. Untreated, mental disorders can lead to lost productivity, unsuccessful relationships, and significant distress and dysfunction. Mental illness in adults can have a significant and continuing effect on children in their care. 3. Stressful life events or the manifestation of mental illness can disrupt the balance adults seek in life and result in distress and dysfunction. Severe or life-threatening trauma experienced either in childhood or adulthood can further provoke emotional and behavioral reactions that jeopardize mental health. 4. Research has improve3 our understanding of mental disorders in the adult stage of the life cycle. Anxiety, depression, and schizophrenia, particularly, present special problems in this age group. Anxiety and depression contribute to the high rates of suicide in this population. Schizophrenia is the most persistently disabling condition, especially for young adults, in spite of recovery of function by some individuals in mid to late life. 5. Research has contributed to our ability to recognize, diagnose, and treat each of these conditions effectively in terms of symptomcontrol and behavior management. Medication and other therapies can be independent, combined, or sequenced depending on the individual's diagnosis and personal preference. 6. A new recovery perspective is supported by evidence on rehabilitation and treatment as well as by the personal experiences of consumers. 7. Certain common events of midlife (e.g., divorce or other stressful life events) create mental health problems (not necessarily disorders) that may be addressed through a range of interventions. 8. Care and treatment in the real world of practice do not conform to what research determines is best. For many reasons, at times care is inadequate, but there are models for improving treatment. 9. Substance abuse is a major co-occurring problem for adults with mental disorders. Evidence supports combined treatment, although there are substantial 18 gaps between what research recommends and what typically is available in communities. ,o, Sensitivity to culture, race, gender, disability, poverty. and the need for consumer involvement are important considerations for care and treatment. ,I. Bat-tiers of access exist in the organization and financing of services for adults. There are specific problems with Medicare, Medicaid, income supp~m, housing, and managed care. Chapter 5: Older Adults and Mental Health 1. Important life tasks remain for individuals as they age. Older individuals continue to learn and contribute to the society, in spite of physiologic changes due. to aging and increasing health problems. 1 -. Continued intellectual, social, and physical activity throughout the life cycle. are important for the maintenance of mental health in late life. !. Stressful life events, such as declining health and/or the loss of mates, family members, or friends often increase with age. However, persistent bereavement or serious depression is not "normal" and should be treated. 4. Normal aging is not characterized by mental or cognitive disorders. Mental or substance use disorders that present alone or co-occur should be recognized and treated as illnesses. 5. Disability due to mental illness in individuals over 65 years old will become a major public health problem in the near future because of demographic changes. In particular, dementia, depression, and schizophrenia, among other conditions, will all Present special problems in this age group: a. Dementia produces significant dependency and is a leading contributor to the need for costly long-term care in the last years of life; b. Depression contributes to the high rates of suicide among males in this population; and c. Schizophrenia continues to be disabling in spite of recovery of function by some individuals in mid to late life. 6. There are effective interventions for most mental disorders experienced by older persons (for 7. 8. 9. Introduction and Themes example, depression and anxiety), and many mental health problems, such as bereavement. Older individuals can benefit from the advances in psychotherapy, medication, and other treatment interventions for mental disorders enjoyed by younger adults, when these interventions are modified for age and health status. Treating older adults with mental disorders accrues other benefits to overall health by improving the interest and ability of individuals to care for themselves and follow their primary care provider's directions anaadvice, particularly about taking medications. Primary care practitioners are a critical link in identifying and addressing mental disorders in older adults. Opportunities are missed to improve mental health and general medical outcomes when mental illness is underrecognized and undertreated in primary care settings. 10. Barriers to access exist in the organization and financing of services for aging citizens. There are specific problems with Medicare, Medicaid, nursing homes, and managed care. Chapter 6: Organization and Financing of Mental Health Services In the United States in the late 20th century, research- based capabilities to identify, treat, and, in some instances, prevent mental disorders is outpacing the capacities of the service system the Nation has in place to deliver mental health care to all who would benefit from it. Approximately 10 percent of children and adults receive mental health services from mental health specialists or general medical providers in a given year. Approximately one in six adults, and one in five children, obtain mental health services either from health care providers, the clergy, social service agencies, or schools in a given year. Chapter 6 discusses the organization and financing of mental health services. The chapter provides an overview of the current system of mental health services, describing where people get care and how they use services. The chapter then presents information on the costs of care and trends in spending. 19 Mental Health: A Report of the Surgeon General Only within recent decades, in the face of concerns about discriminatory policies in mental health financing, have the dynamics of insurance financing become a significant issue in the mental health field. In particular, policies that have emphasized cost containment have ushered in managed care. Intensive research currently is addressing both positive and adverse effects of managed care on access and quality, generating information that will guard against untoward consequences of aggressive cost-containment policies. Inequities in insurance coverage for mental health and general medical care-the product of decades of stigma and discrimination-have prompted efforts to correct them through legislation designed to produce financing changes and create parity. Parity calls for equality between mental health and other health coverage. 1. Epidemiologic surveys indicate that one in five Americans has a mental disorder in any one year. 2. Fifteen percent of the adult population use some form of mental health service during the year. Eight percent have a mental disorder; 7 percent have a mental health problem. 3. Twenty-one percent of children ages 9 to 17 receive mental health services in a year. 4. The U.S. mental health service system is complex and connects many sectors (public-private, specialty-general health, health-social welfare, housing, criminal justice, and education). As a result, care may become organizationally fragmented, creating barriers to access. The system is also financed from many funding streams, adding to the complexity, given sometimes competing incentives between funding sources. 5. In 1996, the direct treatment of mental disorders, substance abuse, and Alzheimer's disease cost the Nation $99 billion; direct costs for mental disorders alone totaled $69 billion. In 1990, indirect costs for mental disorders alone totaled $79 billion. 6. Historically, financial barriers to mental health services have been attributable to a variety of economic forces and concerns (e.g., market failure, adverse selection, moral hazard, and public provision). This has accounted for differential resource allocation rules for financing mental health services. a. "Parity" legislation has been a partial solution to this set of problems. b. Implementing parity has resulted in negligible cost increases where the care has been managed. 7. In recent years, managed care has begun to introduce dramatic changes into the organization and financing of health and mental health services. 8. Trends indicate that in some segments of the private sector per capita mental health expenditures have declined much faster than they have for other conditions. 9. There is little direct evidence of problems with quality in well-implemented managed care programs. The risk for more impaired populations and children remains a serious concern. 10. An array of quality monitoring and quality improvement mechanisms has been developed, although incentives for their full implementation has yet to emerge. In addition, competition on the basis of quality is only beginning in the managed care industry. 11. There is increasing concern about consumer satisfaction and consumers' rights. A Consumers Bill of Rights has been developed and implemented in Federal Employee Health Benefit Plans, with broader legislation currently pending in the Congress. Chapter 7: Confidentiality of Mental Health Information: Ethical, legal, and Policy Issues In an era in which the confidentiality of all health care information, its accessibility, and its uses are of concern to all Americans, privacy issues are particularly keenly felt in the mental health field. An assurance of confidentiality is understandably critical in individual decisions to seek mental health treatment. Although an extensive legal framework governs confidentiality of consumer-provider interactions, potential problems exist and loom ever larger. 1. people's willingness to seek help is contingent on their confidence that personal revelations of mental distress will not be disclosed without their consent. 2. The U.S. Supreme Court recently has upheld the right to the privacy of these records and the therapist-client relationship. 3. Although confidentiality issues are common to health care in general, there are special concerns for mental health care and mental health care records because of the extremely personal nature of the material shared in treatment. 4. State and Federal laws protect the confidentiality of health care information but are often incomplete because of numerous exceptions which often vary from state to state. Several states have imple- mented or proposed models for protecting privacy that may serve as a guide to others. 5. States, consumers, and family advocates take differing positions on disclosure of mental health information without consent to family caregivers. In states that allow such disclosure, information provided is usually limited to diagnosis, prognosis, and information regarding treatment, specifically medication. 0. When conducting mental health research, it is in the interest of both the researcher and the individual participant to address informed consent and to obtain certificates of confidentiality before proceeding. Federal regulations require informed consent for research being conducted with Federal funds. 7. New approaches to managing care and information technology threaten to further erode the confidentiality and trust deemed so essential between the direct provider of mental health services and the individual receiving those services. It is important to monitor advances so that confidentiality of records is enhanced, instead of impinged upon, by technology. 8. Until the stigma associated with mental illnesses is addressed, confidentiality of mental health information will continue to be a critical point of concern for payers, providers, and consumers. Introduction and Themes Chapter 8: A Vision for the Future- Actions for Mental Health in the New Millennium The extensive literature that the Surgeon General's report reviews and summarizes leads to the conclusion that a range of treatments of documented efficacy exists for most mental disorders. Moreover, a person may choose a particular approach to suit his or her needs and preferences. Based on this finding, the report's principal recommendation to the American people is to seek help if you have a mental health problem or think you have symptoms of a mental disorder. As noted earlier, stigma interferes with the willingness of many people--even those who have a serious mental illness-to seek help. And, as documented in this report, those who do seek help will all too frequently learn that there are substantial gaps in the availability of state-of-the-art mental health services and barriers to their accessibility. Accordingly, the final chapter of the report goes on to explore opportunities to overcome barriers to implementing the recommendation and to have seeking help lead to effective treatment. The final chapter identifies the following courses of action. 1. Continue to Build the Science Base: Today, integrative neuroscience and molecular genetics present some of the most exciting basic research opportunities in medical science. A plethora of new pharmacologic agents and psychotherapies for mental disorders afford new treatment opportunities but also challenge the scientific community to develop new approaches to clinical and health services interventions research. Because the vitality and feasibility of clinical research hinges on the willing participation of clinical research volunteers, it is important for society to ensure that concerns about protections for vulnerable research subjects are addressed. Responding to the calls of managed mental and behavioral health care systems for evidence-based interventions will have a much needed and discernible impact on practice. Special effort is required to address pronounced gaps in the mental 31 Mental Health: A Report of the Surgeon General health knowledge base. Key among these are the urgent need for evidence which supports strategies for mental health promotion and illness prevention. Additionally, research that explores approaches for reducing risk factors and strengthening protective factors for the prevention of mental illness should be encouraged. As noted throughout the report, high-quality research and the effective services it promotes are a potent weapon against stigma. 2. Overcome Stigma: Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others. For our Nation to reduce the burden of mental illness, to improve access to care, and to achieve urgently needed knowledge about the brain, mind, and behavior, stigma must no longer be tolerated. Research on brain and behavior that continues to generate ever more effective treatments for mental illnesses is a potent antidote to stigma. The issuance of this Surgeon General's Report on Mental Health seeks to help reduce stigma by dispelling myths about mental illness, by providing accurate knowledge to ensure more informed consumers, and by encouraging help seeking by individuals experiencing mental health problems. 3. ImprovePublicAwarenessofEffective Treatment: Americans are often unaware of the choices they have for effective mental health treatments. In fact, there exists a constellation of several treatments of documented efficacy for most mental disorders. Treatments fall mainly under several broad catego- ries-counseling, psychotherapy, medication ther- apy, rehabilitation-yet within each category are many more choices. All human services professionals, notjust health professionals, have an obligation to be better informed about mental health treatmentresources in theircommunities and should encourage individuals to seek help from any source in which they have confidence. 4. Ensure the Supply of Mental Health Services and Providers: The fundamentalcomponents ofeffective service delivery, which include integrated community-based services, continuity of providers and treatments, family support services (including psychoeducation),andculturallysensitiveservices, are broadly agreed upon, yet certain of these and other mental health services are inconsistently short supply, both regionally and, in some instances, nationally. Because the service systemasawhole, as opposed to treatment services considered in isolation, dictates the outcome of recovery-oriented mental health care, it is imperative to expand the supply of effective, evidence-based services throughout the Nation. Key personnel shortages include mental healt'h, professionals serving children/adolescents and older people with serious mental disorders and specialists with expertise in cognitive-behavioral therapy and interpersonal therapy, two forms of psychotherapy that research has shown to be effective for several severe mental disorders. For adults and children with less severe conditions, primary health care, the schools, and otherhumanservicesmustbepreparedtoassessand, at times, to treat individuals who come seeking help. 5. Ensure Delivery of State-of-the-Art Treatments: A wide variety of effective, community-based services, carefully refined through years of research, exist for even the most severe mental illnesses yet are not being translatedinto community settings. Numerous explanationsforthegapbetweenwhatisknownfrom research and what is practiced beg for innovative strategies to bridge it. 6. Tailor Treatment to Age, Gender, Race, and Culture: Mental illness, no less than mental health, is influencedby age, gender,race, and culture as well as additional facets of diversity that can be found within all of these population groups-for example, physical disability or a person's sexual orientation choices. To be effective, the diagnosis and treatment of mental illness must be tailored to all characteristics that shape a person's image and identity. The consequences of not understanding these influences can be profoundly deleterious. "Culturally competent" services incorporate understanding of racial and ethnic groups, their histories,traditions, beliefs,andvaluesystems. With appropriate training and a fundamental respect for 33 clients, any mental health professional can provide culturallycompetentservicesthatreflectsensitivity toindividualdifferencesand,atthesametime,assign validity to an individual's group identity. Nonetheless, the preference of many members of ethnic and racial minority groups to be treated by lnental health professionals of similar background underscores the need to redress the current insufficient supply of mental health professionals \++o are members of racial and ethnic minority k'roups. 7. La&tate Entry Into Treatment: Public and private agencies have an obligation to facilitate entry into Imental health care and treatment through' the multiple "portals of entry" that exist: primary health care, schools, and the child welfare system. To enhance adherence to treatment, agencies should offer services that are responsive to the needs and preferencesofserviceusersandtheirfamilies.Atthe same time, some agencies receive inappropriate referrals. For example, an alarming number of children and adults with mental illness are in the criminaljusticesysteminappropriately.Importantly, assuringthesmallnumberofindividualswithsevere mental disorders who pose a threat of danger to themselves or others ready access to adequate and appropriate services promises to reduce significantly the rreed for coercion in the form of involuntary commitment to a hospital andfor certain outpatient treatment requirements that have been legislated in most states and territories. Coercion should not be a substitute for effective care that is sought voluntarily; consensus on this point testifies to the need for research designed to enhance adherence to treatment. 8. Reduce Financial Barriers to Treatment: Concerns about the cost of care-concerns made worse by the disparity in insurance coverage for mental disorders in contrast to other illnesses-are among the foremost reasons why people do not seek needed mental health care. While both access to and use of mental health services increase when benefits for those services are enhanced, preliminary data show that the effectiveness-and, thus, the value-of Introduction and Themes mental health care also has increased in recent years, while expenditures for services, under managed care. have fallen. Equality between mental health coverage and other health coverage-a concept known as parity-is an affordable and effective objective. Scope of Coverage of the Report This report is comprehensive but not exhaustive in its coverage of mental healthandmental illness. It considers mental health facets of some conditions which are not always associated with thementaldisorders and does not consider all conditions which can be found in classifications of mental disorders such as DSM-IV. The report includes, for example, a discussion of autism in Chapter 3 and provides an extensive section on Alzheimer's disease in Chapter 5. Although DSM-IV lists specific mental disorder criteria for both of these conditions, they often are viewed as being outside the scope of the mental health field. In both cases, mental health professionals are involved in the diagnosis and treatment of these conditions, often characterized by cognitive and behavioral impairments. The developmentaldisabilitiesandmentalretardationarenot discussed except in passing in this report. These conditions were considered to be beyond its scope with a care system all their own and very special needs. The same is generally true for the addictive disorders, such as alcohol andotherdruguse disorders. The latter, however, co-occur with such frequency with the other mental disorders, which are the focus of this report, that the co- occurrenceisdiscussedthroughout.Thereportcoversthe epidemiology of addictive disorders and their co- occurrence with other mental disorders as well as the treatment of co-occurring conditions. Brief sections on substance abuse in adolescence and late life also are included in the report. Preparation of the Report In September 1997, the Office of the Surgeon General, with the approval of the Secretary of the Department of Health and Human Services, authorized the Substance Abuse and Mental Health Services Administration (SAMHSA) to serve as lead operating division for 33 Mental Health: A Report of the Surgeon General preparing the first Surgeon General's Report on Mental Health. SAMHSA's Center for Mental Health Services worked in partnership with the National Institute of Mental Health of the National Institutes of Health to develop this report under the guidance of Surgeon General David Satcher. These Federal partners established a Planning Board comprising individuals representing a broad range of expertise in mental health, including academicians, mental health professionals, researchers in neuroscience and service delivery, and self-identified consumers of mental health services and family members of consumers of mental health services. Also included on the Planning,Board were individuals representing Federal operating divisions, offices, centers, and institutes and private nonprofit foundations with interests in mental health. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angermeyer, M. C., & Matschinger, H. (1996). The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill. Social Science Medicine, 43, 172 l-l 728. Bachrach, L. L. ( 1996). The state of the state mental hospital 1996. Psychiatric Services, 47, 1071-1078. Baum, A., & Posluszny, D. M. (1999). Health psychology: Mapping biobehavioral contributions to health and illness. Annual Review of Psychology, 50, 137-163. Chambless, D. L., Sanderson, W. C., Shohman, V., Bennett, J. S., Pope, K. S., Crits-Ctistoph, P., Baker, M., Johnson, B., Woody, S. R., Sue, S., Beutler, L., Williams, D. A., & McMurry, S. (1996). An update on empirically validated therapies. Clinical Psychologist, 49, 5-18. Cohen. S., & Herbert, T. B. (1996). Health psychology: Psychological factors and physical disease from the perspective of human psychoneuroimmunology. Annual Review of Psychology, 47, 113-142. Conwell, Y. (1996). Diagnosis and treatment of depression in late life. Washington, DC: American Psychiatric Press. Cooper-Patrick, L., Powe, N. R., Jenckes, M. W., Gonzales, J. J., Levine, D. M., & Ford, D: E. (1997). Identification of patient attitudes and preferences regarding treatment of depression. Journal of General InternalMedicine, 12, 431-438. Conigan, P. W. & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765-776. Cowen, E. L. (1994). The enhancement of psychological wellness: Challenges and opportunities. American Journal of Community Psychology, 22, 149-179. DiMasi, J. A., & Lasagna, L. (1995). The economics of psychotropic drug develOpment. In F. E. Bloom & D. J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress. (pp. 1883-1895). New York: Raven Press. DSM-IV. See American Psychiatric Association (1994). Eisendrath, S. J., & Feder, A. (in press). The mind and somatic illness: Psychological factors affecting physical illness. In H. H. Goldman (Ed.), Review of general psychiatry (5th ed.). Norwalk, CT: Appleton & Lange. Eronen, M., Angermeyer, M. C., & Schulze, B. (1998). The psychiatric epidemiology of violent behaviour. Social Psychiatry and Psychiatric Epidemiology, 33(Suppl. l), S13-S23. Fischbach, G. D. (1992). Mind and brain. Scientific American, 267,48-57. Food and Drug Administration. (1998). Center for Drug Evaluation and Research handbook [On-line]. Available: http://www.fda.gov/cder/ handbook- /index.htm Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). Depression following myocardial infarction. Impact on 6-month survival. Journal of the American Medical Association, 270, 1819-1825. Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). Depression and 18-month prognosis after myocardial infarction. Circulation, 91,999-1005. Gazzaniga, M. S., Ivry, R. B., & Mangun, G. R. (1998). Cognitive neuroscience: The biology of the mind. New York: W. W. Norton. Grob, G. N. (1983). Mental illness and American society, I875-1940. Princeton, NJ: Princeton University Press. Grob, G. N. (1991). From asylum to community Mental health policy in modem America. Princeton, NJ: Princeton University Press. Introduction and Themes (;toh.c;. N. ( 1994). Themadamongus:Ahistoryofthecareof ,.\mer;ca's mentally ill. New York: Free Press. (;ci.n,. J ,. Veroff. J.. & Feld, S. (1960).Americans view their r,,r,,rcI~~~ealtl~:A nationwideinterviewsurvey(Areportto thestaffdirector,JackR.Ewah).NewYork:BasicBooks. Hanson. K. w. (1998). Public opinion and the mental health parity debate: Lessons from the survey literature. psxchiatric Sensices, 49, 1059-1066. l{c,.inbotham.C.( 1998).UKmentalhealthpolicycanalterthe ,tigmaofmental illness. Lancer, .?52,1052-1053. Hoyt. D. R.. Conger. R. D., Valde, J. G., & Weihs, K. (1997). psychological distress and help seeking inrural America. ,American Journal of Community Psychology, 25, UY--t70. J,,nes. A. H. (1998). Mental illness made public: Ending the stigma? Lancer, 352,106O. K;indcl. E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry, 155, 357369. Kc\\ler. R. C., Nelson, C. B.,McKinagle,K.A.,Edlund,M. J., Frank.R.G.,&Leaf,P.J.(1996).Theepidemiologyofco- occurringaddictiveandmentaldisorders:Implicationsfor prevention and service utilization. American Journal of Orthopsychiatry, 66, 17-3 1. I .a\~. J. M.. & Wallace, R. B. (Eds.). (1992). Maxcy-Rosenau- Last public health and preventive medicine (13th ed.). Norwalk, CT: Appleton and Lange. I .ink. B.. Phelan,J.,Bresnahan,M.,Stueve,A.,&Pescosolido, B. (in press). Public conceptions of mental illness: The labels. causes, dangerousness and social distance. ,%rierican Journal of Public Health. xlul-rq', C. J. L., & Lopez, A. D. (Eds.). (1996). The globai burden of disease. A comprehensive assessment of mortality and disabilityfrom diseases, injuries, and risk Jitctors in 1990 andprojected to 2020. Cambridge, MA: Harvard School of Public Health. Penn. D. L., & Martin, J. (1998). The stigma of severe mental illness: Some potential solutions for a recalcitrant problem. Psychiatric Quarterly, 69,235-247. Phelan, J., Link, B., Stueve, A., & Pescosolido, B. (1997, August). Public conceptions of mental illness in 19% in 1996: Has sophistication increased? Has stigma declined? Paper presented at the meeting of the American Sociological Association, Toronto, Ontario. Regier,D.A.,Narrow,W.E.,Rae,D.S.,Manderscheid,R.W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective l-year prevalence rates of disorders and services. Archives of General Psychiatry, 50,85-94. Seeker, J. (1998). Currentconceptualizationsof mental health andmental healthpromotion. HealthEducation Research, 13,57-66. Star,S. A. (1952). Whatthepublicthinksaboutmentalhealth and mental illness. Paper presented at the annual meeting of the National Association for Mental Health. Star, S. A. (1955). The public's ideas about mental illness. Paper presented at the annual meeting of the National Association for Mental Health. Steadman, H. J., Mulvey, E. P., Monahan, J., Robbins, P. C., Appelbaum, P. S., Grisso, T., Roth, L. H., & Silver, E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, 39340 1. Sussman, L. K., Robins, L. N., &Earls, F. (1987). Treatment- seeking for depression by black and white Americans. Social Science and Medicine, 24,187-196. Swanson, J. W. (1994). Mentaldisorder, substance abuse, and community violence: An epidemiological approach. In J. Monahan & H. J. Steadman (Eds.), Violence and mental disorder:Developmentsinriskassessment(pp. 101-136). Chicago: University of Chicago Press. Swartz, M. S., Swanson, J. W., & Bums, B. J. (1998). Taking the wrong drugs: The role of substance abuse and medication noncompliance in violence among severely mentally ill individuals. Social Psychiatry andpsychiatric Epidemiology, 33(Suppl. 1). S75-SSO. Swindle, R., Heller, K., & Pescosolido, B. (1997, August). Responses to "nervous breakdowns" in America over a 40-yearperiod: Mental healthpolicy implications. Paper presented at the meeting of American Sociological Association, Toronto, Ontario. Veroff,J.,Douvan,E.,&Kulka,R.A.(1981).Mentalhealthin America: Patterns of help-seeking from 1957 to 1976. New York: Basic Books. Zisook, S., & Shuchter, S. R. (1991). Depression through the first yearafter the death of a spouse. American Journal of Psychiatry, 148,1346-1352. Zisook, S., & Shuchter, S. R. (1993). Major depression associated with widowhood. American Journal of Geriatric Psychiatry, I, 3 16-326. 25 CHAPTER 2 THE FUNDAMENTALS OF MENTAL HEALTH AND MENTAL ILLNESS . Contents The Neuroscience of Mental Health ................................................. 32 Complexity of the Brain I: Structural ............................................. 32 Complexity of the Brain II: Neurochemical ........................................ 36 Complexity of the Brain III: Plasticity ............................................ 38 ImagingtheBrain ............................................................ 38 Overview of Mental IIlness ........................................................ 39 Manifestations of Mental Illness ................................................ 40 Anxiety .................................................................. 40 Psychosis ............................................................... 41 DisturbancesofMood ..................................................... 42 DisturbancesofCognition .................................................. 43 Other Symptoms.. ........................................................ 43 DiagnosisofMentalIllness .................................................... 43 Epidemiology of Mental Illness ................................................. 45 Adults .................................................................. 46 Children and Adolescents ................................................... 46 OlderAdults.. ........................................................... 48 Future Directions for Epidemiology .............................................. 48 Costs of Mental Illness ........................................................ 49 OverviewofEtiology ............................................................ 49 Biopsychosocial Model of Disease ............................................... 50 Understanding Correlation, Causation, and Consequences ............................ 5 1 Biological Influences on Mental Health and Mental Illness ........................... 52 The Genetics of Behavior and Mental Illness ................................... 52 InfectiousInfluences ...................................................... 54 PANDAS ............................................................ 55 Contents, continued Psychosocial Influences on Mental Health and Mental Jllness .......................... 55 PsychodynamicTheories ................................................... 55 Behaviorism and Social Learning Theory ...................................... 56 The Integrative Science of Mental Illness and Health ................................ 57 Overview of Development, Temperament, and Risk Factors ...................... _ ....... 57 PhysicalDevelopment ........................................................ 58 Theories of Psychological Development ........................................... 59 Piaget: Cognitive Developmental Theory ...................................... 59 Erik Erikson: Psychoanalytic Developmental Theory ............................. 59 John Bowlby: Attachment Theory of Development ............................... 60 Nature and Nurture: The-Ultimate Synthesis ....................................... 60 OverviewofPrevention.. ......................................................... 62 Definitions of Prevention ...................................................... 62 Risk Factors and Protective Factors .............................................. 63 Overview of Treatment ........................................................... 64 Introduction to Range of Treatments .............................................. 64 Psychotherapy ............................................................... 65 PsychodynamicTherapy.. .................................................. 66 BehaviorTherapy ......................................................... 66 Humanistic Therapy ....................................................... 67 PharmacologicalTherapies ..................................................... 68 MechanismsofAction ..................................................... 68 Complementary and Alternative Treatment ..................................... 70 IssuesinTreatment ........................................................... 70 PlaceboResponse ......................................................... 70 BenefitsandRisks ........................................................ 71 Gap Between Efficacy and Effectiveness ....................................... 72 Barriers to Seeking Help .................................................... 72 Overview of Mental Health Services ................................................. 73 Overall Patterns of Use ........................................................ 75 History of Mental Health Services ............................................... 75 CONTENTS, CONTNJED Overview of Cultural Diversity and Mental Health Services .............................. 80 Introduction to Cultural Diversity and Demographics ................................ 81 CopingStyles ............................................................ 82 Family and Community as Resources ............................................. 83 Epidemiology and Utilization of Services ....................................... 84 African Americans ........................................................ 84 Asian Americans/Pacific Islanders ............................................. 85 Hispanic Americans ........................................................ 86 Native Americans ......................................................... 86 Barriers to the Receipt of Treatment ............................................. 86 Help-Seeking Behavior .................................................... 86 Mistrust ................................................................. 86 Stigma .................................................................. 87 Cost .................................................................... 87 ClinicianBias.. .......................................................... 88 Improving Treatment for Minority Groups .......................................... 88 Ethnopsychopharmacology ................................................. 88 Minority-Oriented Services ................................................. 89 Cultural Competence ....................................................... 90 Rural Mental Health Services ................................................... 92 ( Jvcrview of Consumer and Family Movements ........................................ 92 Origins and Goals of Consumer Groups ........................................... 93 Self-HelpGroups ......................................................... 94 Accomplishments of Consumer Organizations ..................................... 95 Family Advocacy ............................................................ 96 (brview of Recovery ............................................................ 97 Introduction and Definitions .................................................... 97 Impact of the Recovery Concept ................................................ 98 conclusions.. ................................................................. 100 Mental Health and Mental Illness Across the Lifespan .............................. 102 Refmnces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 CHAPTER 2 THE FUNDAMENTALS OF MENTAL HEALTH AND MENTAL ILLNESS A vast body of research on mental health and, to an even greater extent, on mental illness constitutes me foundation of this Surgeon General's report. TO understand and better appreciate the content of the chapters that follow, readers outside the mental health field may desire some background information. Thus, this chapter furnishes a "primer" on topics that the report addresses. The chapter begins with an overview of research under way today that is focused on the neuroscience of rncntal health. Modem integrative neuroscience offers ;I mcans of linking research on broad "systems level" ;tspects of brain function with the remarkably detailed tools and findings of molecular biology. The report begins with a discussion of the brain because it is central to what makes us human and provides an understanding of mental health and mental illness. All of human behavior is mediated by the brain. Consider, for example, a memory that most people have from childhood-that of learning to ride a bicycle with the help of a parent or friend. The fear of falling, the anxiety of lack of control, the reassurances of a loved one. and the final liberating experience of mastery and a newly extended universe create an unforgettable combination. For some, the memories are not good ones: falling and being chased by dogs have left marks of anxiety and fear that may last a lifetime. Science is revealing how the skill learning, emotional overtones, and memories of such experiences are put together physically in the brain. The brain and mind are two sides of the same coin. Mind is not possible without the remarkable physical complexity that is built into the brain, but, in addition, the physical complexity of the brain is useless without the sculpting that environment, experience, and thought itself provides. Thus the brain is now known to be physically shaped by contributions from our genes and our experience, working together. This strengthens the view that mental disorders are both caused and can be treated by biological and experiential processes, working together. This understanding has emerged from the breathtaking progress in modem neuroscience that has begun to integrate knowledge from biological and behavioral sciences. An overview of mental illness follows the section on modem integrative brain science. The section highlights topics including symptoms, diagnosis, epidemiology (i.e., research having to do with the distribution and determinants of mental disorders in population groups, including various racial and ethnic minority groups), and cost, all of which are discussed in greater and more pointed detail in the chapters that follow. Etiology is the study of the origins and causes of disease, and that section reviews research that is seeking to define, with ever greater precision, the causes of mental disorders. As will be seen, etiology research examines fundamental biological, behavioral, and so&cultural processes, as well as a necessarily broad array of life events. The section on development of temperament reveals how mental health science has attempted over much of the past century to understand how biological, psychological, and sociocultural factors meld in health as well as in illness. The chapter then reviews research approaches to the prevention and treatment of mental disorders and provides an overview of mental health services and their delivery. Final sections cover the growing influence on the mental 31 Mental Health: A Report of the Surgeon General health field of the need for attention to cultural diversity, the importance of the consumer movement, and new optimism about recovery from mental illness-that is, the possibility of recovering one's life. The Neuroscience of Mental Health' Complexity of the Brain I: Structural As befits the organ of the mind, the human brain is the most complex structure ever investigated by our science. The brain contains approximately 100 billion nerve cells, or neurons, and many more supporting cells, or glia. In and of themselves, the number of cells Figure 2-1. Structural variety of neurons F'URKINJE CELL in this 3-pound organ reveal little of its complexity. Yet most organs in the body are composed of only a handful of cell types; the brain, in contrast, has literally thousands of different kinds of neurons, each distinct in terms of its chemistry, shape, and connections (Figure 2-l depicts the structural variety of neurons). To illustrate, one careful, recent investigation of a kind of interneuron that is a small local circuit neuron in the retina, called the amacrine cell, found no less than 23 identifiable types. But this is only the beginning of the brain's complexity. Source: Fischbach, 1992, p. 53. (Permission granted: Patricia J. Wynne.) ' Special thanks to Steven E. Hyman, M.D., Director, National Institute of Mental Health, and Gerald D. Fischbach, M.D., Director, National Institute of Neurological Diseases and Stroke. for their contributions to this section. 32 The Fundamentals of Mental Health and Mental Illness The workings of the brain depend on the ability of nclr\`e cells to communicate with each other. communication occurs at small, specialized structures C.lled synapses. The synapse typically has two parts. one is a specialized presynaptic structure on a terminal portion of the sending neuron that contains packets of rignalling chemicals, or neurotransmitters. The second is a postsynaptic structure on the dendrites of the fscriving neuron that has receptors for the nrnrotransmitter molecules. The typical neuron has a cell body, which contains [he genetic material, and much of the cell's energy- producing machinery. Emanating from the cell body are dendrites. branches that are the most important receptive surface of the cell for communication. The dendrites of neurons can assume a great many shapes and sizes, all relevant to the way in which incoming messages are processed. The. output of neurons is curried along what is usually a single branch called the axon. It is down this part of the neuron that signals are trunsmitted out to the next neuron. At its end, the axon may branch into many terminals. (Figure 2-2.) The usual form of communication involves clcctrical signals that travel within neurons, giving rise IO chemical signals that diffuse, or cross, synapses, \vhich in turn give rise to new electrical signals in the postsynaptic neuron. Each neuron, on average, makes more than 1,000 synaptic connections with other neurons. One type of cell-a Purkinje cell-may make hctween 100,000 and 200,000 connections with other ncnrons. In aggregate, there may be between 100 trillion and a quadrillion synapses in the brain. These synapses are far from random. Within each region of the brain, there is an exquisite architecture consisting of layers and other anatomic substructures in which WaPtic connections are formed. Ultimately, the Pattern of synaptic connections gives rise to what are called circuits in the brain. At the integrative level, large- and small-scale circuits are the substrates of behavior and of mental life. One of the most awe- insPifing mysteries of brain science is how neuronal activity within circuits gives rise to behavior and, even, consciousness. The complexity of the brain is such that a single neuron may be part of more than one circuit. The organization of circuits in the brain reveals that the brain is a massively parallel, distributed information processor. For example, the circuits involved in vision receive information from the retina. After initial processing, these circuits analyze information into different streams, so that there is one stream of information describing what the visual object is, and another stream is concerned with where the object is in space. The information stream having to do with the identity of the object is actually broken down into several more refined parallel streams. One, for example, analyzes shape while another analyzes color. Ultimately, the visual world is resynthesized with information about the tactile world, and the auditory world, with information from memory, and with emotional coloration. The massively parallel design is a great pattern recoguizer and very tolerant of failure in individual elements. This is why a brain of neurons is still a better and longer-lasting information processor than a computer. The specific connectivity of circuits is, to some degree, stereotyped, or set in expected patterns within the brain, leading to the notion that certain places in the brain are specialized for certain functions (Figure 2-3). Thus, the cerebral cortex, the mantle of neurons with its enormous surface area increased by outpouchings, called gyri, and indentations, called sulci, can be functionally subdivided. The back portion of the cerebral cortex (i.e., the occipital lobe), for example, is involved in the initial stages of visual processing. Just behind the central sulcus is the part of the cerebral cortex involved in the processing of tactile information (i.e., parietal lobe). Just in front of the central sulcus is a part of the cerebral cortex involved in motor behavior (frontal lobe). In the front of the brain is a region called the prefrontal cortex, which is involved with some of the highest integrated functions of the human being, including the ability to plan and to integrate cognitive and emotional streams of information. Beneath the cortex are enormous numbers of axons sheathed in the insulating substance, myelin. This sub- Mental Health: A Report of the Surgeon General Figure 2-2. How neurons communicate Source: Fischbach, 1992, p. 52. (Permission granted: Tomo Narashima.) 34 The Fundamentals of Mental Health and Mental Illness Figure 2-3. The brain: Organ of the mind PlTULT..Y blAND PWIETAL SOUrCe: Fischbach, 1992, p. 51. (Permission granted: Carol Donner.) cortical "white matter," so named because of its the brain processes information. The white matter is appearance on freshly cut brain sections, surrounds akin to wiring that conveys information from one deep aggregations of neurons, or "gray matter," which, region to another. Gray matter regions include the basal Iike the cortex, appears gray because of the presence of ganglia, the part of the brain that is involved in the neuronal cell bodies. It is within this gray matter that initiation of motion and thus profoundly affected in 35 Mental Health: A Report of the Surgeon General Parkinson's disease, but that is also involved in the integration of motivational states and, thus, a substrate of addictive disorders. Other important gray matter structures in the brain include the amygdala and the hippocampus. The amygdala is involved in the assignment of emotional meaning to events and objects, and it appears to play a special role in aversive, or negative, emotions such as fear. The hippocampus includes, among its many functions, responsibility for initially encoding and consolidating explicit or episodic memories of persons, places, and things. In summary, the organization of the brain at the cellular level involves many thousands of distinct kinds of neurons. At a higher integrative level, these neurons form circuits for information processing determined by their patterns of synaptic connections. The organization of these parallel distributed circuits results in the specialization of different geographic regions of the brain for different functions. It is important to state at this point, however, that, especially in younger individuals, damage to a particular brain region may yield adaptations that permit circuits spared the damage and, therefore, other regions of the brain, to pick up some of the functions that would otherwise have been lost. Complexity of the Brain II: Neurochemical Superimposed on this breathtaking structural complexity is the chemical complexity of the brain. As described above, electrical signals within neurons are converted at synapses into chemical signals which then elicit electrical signals on the other side of the synapse. These chemical signals are molecules called neurotransmitters. There are two major kinds of molecules that serve the function of neurotransmitters: small molecules, some quite well known, with names such as dopamine, serotonin, or norepinephrine, and larger molecules, which are essentially protein chains, called peptides. These include the endogenous opiates, Substance P, and corticotropin releasing factor (CRF), among others. All told, there appear to be more than 100 different neurotransrnitters in the brain (Table 2-1 contains a selected list). A neurotransmitter can elicit a biological effect in the postsynaptic neuron by binding to a protein called a neurotransmitter receptor. Its job is to pass the information contained in the neurotransmitter message from the synapse to the inside of the receiving cell. It appears that almost every known neurotransmitter has Table 2-1. Selected neurotransmitters important In psychopharmacology Excitatory amino acid Glutamate Inhibitory amino acids Gamma aminobutyric acid Glycine Monoamines and related neurotransmitters Norepinephrine Dopamine Serotonin Histamine Acetylcholine (quarternary amine) Purine Adenosine Neuropeptides Opioids Enkephalins Beta-endorphin Dynorphin Tachykinin Substance P Hypothalamic-re/easing factors Corticotropin-releasing hormone more than one different kind of receptor that can confer rather different signals on the receiving neuron. Dopamine has 5 known neurotransmitter receptors; serotonin has at least 14. Although there are many kinds of receptors with many different signaling functions, we can divide most neurotransmitter receptors into two general classes. One class of neurotransmitter receptor is called a ligand-gated channel, where "ligand" simply means a 36 The Fundamentals of Mental Health and Mental Illness ,,,olecule (i.e.. a neurotransmitter) that binds to a receptor. When neurotransmitters interact with this kind of receptor, a pore within the receptor molecule itself is opened and positive or negative charges enter [he cell. The entry of positive charge may activate ;,dditional ion channels that allow more positive charge to enter. At a certain threshold, this causes a cell to fire an action potential- an electrical event that leads ultimately to the release of neurotransmitter. By definition. therefore, receptors that admit positive charge are excitatory neurotransmitter receptors. The classic excitatory neurotransmitter receptors in the brain utilize the excitatory amino acids glutamate and, to a lesser degree, aspartate as neurotransmitters. Conversely, inhibitory neurotransmitters act by permitting negative charges into the cell, taking the cell thrther away from firing. The classic inhibitory ncurotransmitters in the brain are the amino acids ~;unma ammo butyric acid, or GABA, and, to a lesser degree. glycine. Most of the other neurotransmitters in the brain, huch as dopamine, serotonin, and norepinephrine, and ;III of the many neuropeptides constitute the second major class. These are neither precisely excitatory nor inhibitory but rather act to produce complex biochemical changes in the receiving cell. Their receptors do not contain intrinsic ion pores but rather intcmct with signaling proteins, called "G proteins" found inside the cell membrane. These receptors thus ;ire called G protein-linked receptors. The details are less important than understanding the general scheme. Stimulation of G protein-linked receptors alters the way in which receiving neurons can process subsequent r*ignals from glutamate or GAB A. To use a metaphor of a musical instrument, if glutamate, the excitatory neurotransmitter, is puffing wind into a flute or clarinet. it is the modulatory neurotransmitters such as doPamine or serotonin that might be seen as playing the keys and. thus, altering the melody via G protein-linked receptors. The architecture of these systems drives home this Point. The precise brain circuits that carry specific information about the world and that are involved in precise point-to-point communication within the brain use excitatory or inhibitory neurotransmission. Examples of such circuits, which are massively parallel, can be found in the visual and auditory cortex. Overlying this pattern of precise, rapid (timing in the range of milliseconds) neurotransmission are the modulatory systems in the brain that use norepinephrine, serotonin, and dopamine. In each case, the neurotransmitter in question is made by a very small number of nerve cells clustered in a limited number of areas in the brain, Of the hundred billion neurons in the brain, only about 500,000, for example, make dopamine-that is, for every 200,000 cells in the brain, only one makes dopamine. Even fewer make norepinephrine. The cell bodies of the dopamine neurons are clustered in a few brain regions, most importantly, regions deep in the brain, in the midbrain, called the substuntia n&u, and the ventral tegmentul urea. Norepinephrine neurons are made in the nucleus locus coeruleus even farther down in the brain stem in a structure called the pow. Serotonin is made by a somewhat larger number of nuclei but, still, not by many cells. Nuclei called the ruphe nuclei spread along the brain stem. While each of these neurotransmitters is made by a small number of neurons with clustered cell bodies, each sends its axons branching throughout the brain, so that in each case a very small number of neurons, which largely appear to fire in unison when excited, influence almost the entire brain. This is not the picture of systems that are communicating precise bits of information about the world but rather are intrinsic modulatory systems that act via other G protein-linked receptors to alter the overall responsiveness of the brain. These neurotransmitters are responsible for brain states such as degree of arousal, ability to pay attention, and for putting emotional color or significance on top of cold cognitive information provided by precise glutaminergic circuits. It is no wonder that these modulatory neurotransmitters and their receptors are critical targets of medications used to treat mental disorders-for example, the antidepressant and antipsychotic drugs-and also are the targets of drugs of abuse. 37 Mental Health: A Report of the Surgeon General Complexity of the Brain III: Plasticity The preceding paragraphs have illustrated the chemical and anatomic structure of the brain and, in so doing, provided some picture of its complexity as well as some picture of its function. The crowning complexity of the brain, however, is that it is not static. The brain is always changing. People learn so much and have so many distinct types of memory: conscious, episodic memory of the sort that is encoded initially in the hippocampus; memory of motor programs or procedures that are encoded in the striatum; emotional memories that can initiate physiologic and behaviorally adaptive repertoires encoded, for example, in the amygdala; and many other kinds. Every time a person learns something new, whether it is conscious or unconscious, that experience alters the structure of the brain. Thus, neurotransmission in itself not only contains current information but alters subsequent neurotransmission if it occurs with the right intensity and the right pattern. Experience that is salient enough to cause memory creates new synaptic connections, prunes away old ones, and strengthens or weakens existing ones. Similarly, experiences as diverse as stress, substance abuse, or disease can kill neurons, and current data suggest that new neurons .continue to develop even in adult brains, where they help to incorporate new memories. The end result is that information is now routed over an altered circuit. Many of these changes are long-lived, even permanent. It is in this way that a person can look back 10 or 20 or 50 years and remember family, a home or school room, or friends. The general theme is that to really understand the kind of memory-indeed, any brain function-one must think at least at two levels: one, the level of molecular and cellular alterations that are responsible for remodeling synapses, and, two, the level of information content and behavior which circuits and synapses serve. To summarize this section, scientists are truly beginning to learn about the structure and function of the brain. Its awe-inspiring complexity is fully consistent with the fact that it supports all behavior and mental life. Implied in the foregoing, is the fact that brains are built not only by genes-and again, it is the lion's share of the 80,000 or so human genes that are involved in building a structure so complex as the brain. Genes are not by themselves the whole story. Brains are built and changed through life through the interaction of genes with environment, including experience. It is true that a set of genes might create repetitive multiples of one type of unit, yet the brain appears far more complex than that. It stands to reason that if 50,000 or 60,000 genes are involved in building a brain that may have 100 trillion or a quadrillion synapses, additional information is needed, and that information comes from the environment. It is this fundamental realization that is beginning to permit an understanding of how treatment of mental disorders works-whether in the form of a somatic intervention such as a medication, or a psychological "talk" therapy-by actually changing the brain. Imaging the Brain There are many exciting developments in brain science. Of great relevance to the study of mental function and mental illness is the ability to image the activity of the living human brain with technologies developed in recent decades, such as positron emission tomography scanning or functional magnetic resonance imaging. Such approaches can exploit surrogates of neuronal firing such as blood flow and blood oxygenation to provide maps of activity. As science learns more about brain circuitry and learns more from cognitive and affective neuroscience about how to activate and examine the function of particular brain circuits, differences between health and illness in the function of particular circuits certainly will become evident. We will be able to see the action of psychotropic drugs and, perhaps most exciting, we will be able to see the impact of that special kind of learning called psychotherapy, which works after all because it works on the brain. Different brain chemicals, brain receptors, and brain structures will come up in the discussion of particular illnesses throughout this document. This section is meant to provide a panoramic, not a detailed, introduction and also to provide certain overarching lessons. When something is referred to as biological or brain-based, that is not shorthand for saying it is 38 ,,enetic and, thus, predetermined; similarly, references 2 to ..psychological" or even "social" phenomena do not Csc]ude biological processes. The brain is the great integrator, bringing together genes and environment. The study of the brain requires reducing problems initially to bite-sized bits that will allow investigators to learn something, but ultimately, the agenda of ,,euroscience is not reductionist; the goal is to cnderstand behavior, not to put blinders on and try to csplain it away. As the foregoing discussion illustrates, rhe brain also is complex. Thus, having a disease that affccts one or even many critical circuits does not overthrow, except in extreme cases, such as advanced .\lzheimer's disease, all aspects of a person. Typically, people retain their personality and, in most cases, their ;lbility to take responsibility for themselves. In retrospect, early biological models of the mind \ccm impoverished and deterministic-for example, ~nodels that held that "levels" of a neurotransmitter huch as serotonin in the brain were the principal intluence on whether one was depressed or aggressive. Neuroscience is far beyond that now, working to integrate information coming "bottom-up" from genes :rnd molecules and cells, with information flowing "top-down" from interactions with the environment and experience to the internal workings of the mind and its ncuronal circuits. Ultimately, however, the goal is not only human self-understanding. In knowing eventually precisely what goes wrong in what circuits and what hynapses and with what chemical signals, the hope is to develop treatments with greater effectiveness and with l&ver side effects. Indeed, as the following chapters indicate, the hope is for cures and ultimately for prevention. There is every reason to hope that as our science progresses, we will achieve those goals. Ckmdew of Mental Illness hlental illness is a term rooted in history that refers collectively to all of the diagnosable mental disorders. Mental disorders are characterized by abnormalities in cognition, emotion or mood, or the highest integrative aspects of behavior, such as social interactions or Planning of future activities. These mental functions are all mediated by the brain. It is, in fact, a core tenet of modem science that behavior and our subjective mental lives reflect the overall workings of the brain. Thus, symptoms related to behavior or our mental lives clearly reflect variations or abnormalities in brain function. On the more difficult side of the ledger are .the terms disorder, disease, or illness. There can be no doubt that an individual with schizophrenia is seriously ill, but for other mental disorders such as depression or attention-deficit/hyperactivity disorder, the signs and symptoms exist on a continuum and there is no bright line separating health from illness, distress from disease. Moreover, the mapifestations of mental disorders vary with age, gender, race, and culture. The thresholds of mental illness or disorder have, indeed, been set by convention, but the fact is that this gray zone is no different from any other area of medicine. Ten years ago a serum cholesterol of 200 was considered normal. Today, this same number alarms some physicians and may lead to treatment. Perhaps every adult in the United States has some atherosclerosis, but at what point does this move along a continuum from normal into the realm of illness? Ultimately, the dividing line has to do with severity of symptoms, duration, and functional impairment. Despite the existence of a gray zone between health and illness, science can study the mechanisms by which illness occurs. Indeed, understanding mood regulation and its abnormalities, for example, proceeds independently from any set of diagnostic clinical criteria. Family studies, molecular genetics strategies, epidemiology, and the tools of clinical investigation tailored to specific populations are being used to investigate the mechanisms of mental illness. Specific manifestations of mental illness will be covered in succeeding pages. This overview of mental illness focuses on those features of the disease process that are most common and characteristic of these disorders. The chapters that follow will present specific details about major categories of mental disorders that occur across the life span. The purpose here is to provide a framework upon which subsequent discussions of specific disorders can rest. The section leads with a descriptive overview of the cardinal manifestations, signs, and symptoms of The Fundamentals of Mental Health and Mental Illness 39 Mental Health: A Report of the Surgeon General mental disorders. It then describes how mental disorders are diagnosed and classified and provides an overview of the epidemiology and societal burden of mental disorders. Manifestations of Mental Illness Persons suffering from any of the severe mental disorders present with a variety of symptoms that may include inappropriate anxiety, disturbances of thought and perception, dysregulation of mood, and cognitive dysfunction. Many of these symptoms may be relatively specific to a particular diagnosis or cultural influence. For example, disturbances of thought and perception (psychosis) are most commonly associated with schizophrenia. Similarly, severe disturbances in expression of affect and regulation of mood are most commonly seen in depression and bipolar disorder. However, it is not uncommon to see psychotic symptoms in patients diagnosed with mood disorders or to see mood-related symptoms in patients diagnosed with schizophrenia. Symptoms associated with mood, anxiety, thought process, or cognition may occur in any patient at some point during his or her illness. Anxiety Anxiety is one of the most readily accessible and easily understood of the major symptoms of mental disorders. Each of us encounters anxiety in many forms throughout the course of our routine activities. It may often take the concrete formof intense fear experienced in response to an immediately threatening experience such as narrowly avoiding a traffic accident. Experiences like this are typically accompanied by strong emotional responses of fear and dread as well as physical signs of anxiety such as rapid heart beat and perspiration. Some of the more common signs and symptoms of anxiety are listed in Table 2-2. Anxiety is aroused most intensely by immediate threats to one's safety, but it also occurs commonly in response to dangers that are relatively remote or abstract. Intense anxiety may also result from situations that one can only vaguely imagine or anticipate, Anxiety has evolved as a vitally important physiological response to dangerous situations that pre- Table 2-2. Common signs of acute anxiety . Feelings of fear or dread \ . Trembling, restlessness, and muscle tension . Rapid heart rate . Lightheadedness or dizziness . Perspiration . Cold hands/feet . Shortness of breath pares one to evade or confront a threat in the environment. The appropriatti regulation of anxiety is critical to the survival of virtually every higher organism in every environment. However, the mechanisms that regulate anxiety may break down in a wide variety of circumstances, leading to excessive or inappropriate expression of anxiety. Specific examples include phobias, panic attacks, and generalized anxiety. In phobias, high-level anxiety is aroused by specific situations or objects that may range from concrete entities such as snakes, to complex circumstances such as social interactions or public speaking. Panic attacks are brief and very intense episodes of anxiety that often occur without a precipitating event or stimulus. Generalized anxiety represents a more diffuse and nonspecific kind of anxiety that is most often experienced as excessive worrying, restlessness, and tension occurring with a chronic and sustained pattern. In each case, an anxiety disorder may be said to exist if the anxiety experienced is disproportionate to the circumstance, is difficult for the individual to control, or interferes with normal functioning. In addition to these common manifestations of anxiety, obsessive-compulsive disorder and post- traumatic stress disorder are generally believed to be related to the anxiety disorders. The specific clinical features of these disorders will be described more fully in the following chapters; however, their relationship to anxiety warrants mention in the present context. In the case of obsessive-compulsive disorder, individuals experience a high level of anxiety that drives their obsessional thinking or compulsive behaviors. When such an individual fails to carry out a repetitive 40 The Fundamentals of Mental Health and Mental Illness khdvior such as hand washing or checking, there is an ,,ps+nce of severe anxiety. Thus while the outward ,,,~nifestations of obsessive-compulsive disorder may rCem fO be related to other anxiety disorders, there .1ppet;lrs to be a strong component of abnormal rC,,uiation of anxiety underlying this disorder. Post- truumatic stress disorder is produced by an intense and ,,,.cnvhejmjngly fearful event that is often life- tureatening in nature. The characteristic symptoms that rc,ult from such a traumatic event include the persistent reesperience of the event in dreams and memories, persistent avoidance of stimuli associated with the cvcnt. and increased arousal. Psychosis l)ihturbances of perception and thought process fall into a broad category of symptoms referred to as Il`;ychosis. The threshold for. determining whether ttlmyht is impaired varies somewhat with the cultural context. Like anxiety, psychotic symptoms may occur III ;I wide variety of mental disorders. They are most characteristically associated with schizophrenia, but Ilsychotic symptoms can also occur in severe mood disorders. One of the most common groups of symptoms that rcsu I t from disordered processing and interpretation of \cnsory information are the hallucinations. Ilallucinations are said to occur when an individual cxpcriences a sensory impression that has no basis in rcillity. This impression could involve any of the ~nsory modalities. Thus hallucinations may be auditory, olfactory, gustatory, kinesthetic, tactile, or visual. For example, auditory hallucinations frequently involve the impression that one is hearing a voice. In each case, the sensory impression is falsely experienced as real. A more complex group of symptoms resulting from disordered interpretation of information consists of delusions. A delusion is a false belief that an individual holds despite evidence to the contrary. A common example is paranoia, in which a person has delusional beliefs that others are trying to harm him or her. Attempts to persuade the person that these beliefs are unfounded typically fail and may even result in the further entrenchment of the beliefs. Hallucinations and delusions are among the most commonly observed psychotic symptoms. A list of other symptoms seen in psychotic illnesses such as schizophrenia appears in Table 2-3. Symptoms of schizophrenia are divided into two broad classes: positive symptoms and negative symptoms. Positive symptoms generally involve the experience of something in consciousness that should not normally be present. For example, hallucinations and delusions represent perceptions or beliefs that should not normally be expirienced. In addition to hallucinations and delusions, patients with psychotic disorders such as schizophrenia fre- quently have marked disturbances in the logical process of their thoughts. Specifically, psychotic thought processes are characteristically loose, disorganized, illogical, or bizarre. These disturbances in thought process frequently produce observable patterns of behavior that are also disorganized and bizarre. The severe disturbances of thought content and process that comprise the positive symptoms often are the most recognizable and striking features of psychotic disorders such as schizophrenia or manic depressive illness. Table 2-3. Common manifestations of schizophrenia Positive Symptoms . Hallucinatidns . Delusions . Disorganized thoughts and behaviors . Loose or illogical thoughts . Agitation Negative Symptoms . Flat or blunted affect . Concrete thoughts . Anhedonia (inability to experience pleasure) . Poor motivation, spontaneity, and initiative However, in addition to positive symptoms, patients with schizophrenia and other psychoses 41 Mental Health: A Report of the Surgeon General have been noted to exhibit major deficits in motivation and spontaneity that are referred to as negative symptoms. While positive symptoms represent the presence of something not normally experienced, negative symptoms reflect the absence of thoughts and behaviors that would otherwise be expected. Concreteness of thought represents impairment in the ability to think abstractly. Blunting of affect refers to a general reduction in the ability to express emotion. Motivational failure and inability to initiate activities represent a major source of long-term disability in schizophrenia. Anhedonia reflects a deficit in the ability to experience pleasure and to react appropriately. to pleasurable situati,ons. Positive symptoms such as hallucinations are responsible for much of the acute distress associated with schizophrenia, but negative symptoms appear to be responsible for much of the chronic and long-term disability associated with the disorder. The psychotic symptoms represent manifestations of disturbances in the flow, processing, and interpretation of information in the central nervous system. They seem to share an underlying commonality of mechanism, insofar as they tend to respond as a group to specific pharmacological interventions. However, much remains to be learned about the brain mechanisms that lead to psychosis. Disturbances of Mood Most of us have an immediate and intuitive understanding of the notion of mood. We readily comprehend what it means to feel sad or happy. These concepts are nonetheless very difficult to formulate in a scientifically precise and quantifiable way; the challenge is greater given the cultural differences that are associated with the expression of mood. In turn, disorders that impact on the regulation of mood are relatively difficult to define and to approach in a quantitative manner. Nevertheless, dysregulation of mood and the expression of mood, or affect, represent a major category among mental disorders. Disturbances of mood characteristically manifest themselves as a sustained feeling of sadness or sustained elevation of mood. As with anxiety and psychosis, disturbances of mood may occur in a variety of patterns associated with .different mental disorders. The disorder most closely associated with persistent sadness is major depression, while that associated with sustained elevation or fluctuation of mood is bipolar disorder. The most common signs of these mood disorders are listed in Table 2-4. Along with the prevailing feelings of sadness or elation, disorders of mood are associated with a host of related symptoms that include disturbances in appetite, sleep patterns, energy level, concentration, and memory. Table 2-4. Common signs of mood disorders Symptoms Commonly Associated With Depression . Psychomotor retardation i Irritability I I* Suicidal ideation I Symptoms Commonly Associated With Mania ~I') `,p-*.v**;`r$.~i " 1 ~Yf$ersis :sx: (" Grandiosity (inappropriately high self-esteem) / Decreased sleep 42 The Fundamentals of Mental Health and Mental Illness lt is not known why diverse functions such as ,leep and appetite should be altered in disorders of nlood. However, depression and mania are typically ,ssociated with characteristic changes in these basic functions. Mood appears to represent a ,.umplex group of behaviors and responses that undergo precise and tightly controlled regulation. Higher organisms that must adapt to changing suvironments depend on optimal control of basic functions such as sleep, appetite, sex, and physical ;ictivity. This regulation must adapt to diurnal and seasonal changes in the environment. In addition, more complex behaviors such as exploration, aggression, and social interaction must also undergo a similar, perhaps closely linked, regulation. In humans, these complex behaviors and their regulation are believed to be associated with the expression of mood. A depressed mood appears to reflect a kind of global damping of these t'unctions, while a manic state may result from an excessive activation of these same functions. The mechanisms underlying the diverse changes associated with the mood disorders are largely unknown, but their appearance as clusters in specific disorders along with their collective response to specific therapeutics suggests a common mechanistic basis. Disturbances of Cognition Cognitive function refers to the general ability to organize, process, and recall information. Cognitive tasks may be subdivided into a large number of more specific functions depending on the nature of the information remembered and the circumstances of its recall. In addition, there are many functions commonly associated with cognition such as the ability to execute complex sequences of tasks. Disturbances of cognitive function may occur in a variety of disorders. Progressive deterioration of cognitive function is referred to as dementia. Dementia may be caused by a number of specific conditions including Alzheimer's disease (to be discussed in subsequent chapters). Impairment of cognitive function may also occur in other mental disorders such as depression. It is not uncommon to find profound disturbances of cognition in patients suffering from severe mood disturbances. More recently, cognitive deficits have been reported in schizophrenia and now have become a major new topic of research. Lastly, cognitive impairment .frequently occurs in a host of chemical, metabolic, and infectious diseases that exert an impact on the brain. The manifestations of cognitive impairment can vary across an extremely wide range, depending on severity. Short-term memory is one of the earliest functions to be affected and, as severity increases, retrieval of more remote memories becomes more difficult. Attention, concentration, and higher intellectual functions can be impaired as the underlying disease process progresses. Language difficulties range from mild word-finding problems to complete inability to comprehend or use language. Functional impairments associated with cognitive deficits can markedly interfere with the ability to perform activities of daily living such as dressing and bathing. Other Symptoms Anxiety, psychosis, mood disturbances, and cognitive impairments are among the most common and disabling manifestations of mental disorders. It is important, however, to appreciate that mental disorders leave no aspect of human experience untouched. It is beyond the scope of the present chapter to detail the full spectrum of presentations of mental disorders. Other common manifestations include, for example, somatic or other physical symptoms and impairment of impulse control. Many of these issues will be touched upon in subsequent chapters with reference to specific disorders. Diagnosis of Mental Illness The foregoing discussion has suggested that the manifestations of mental disorders fall into a number of distinct categories such as anxiety, psychosis, mood disturbance, and cognitive 43 Mental Health: A Report of the Surgeon General deficits. These categories are broad, heterogeneous, and somewhat overlapping. Moreover, any particular patient may manifest symptoms from more than one of these categories. This is not unexpected, given the highly complex interactions that take place among the neurobiological and behavioral substrates that produce these symptoms. Despite these confounding difficulties, a systematic approach to the classification and diagnosis of mental illness has been developed. Diagnosis is essential in all areas of health for shaping treatment and supportive care, establishing a prognosis, and preventing related disability. Diagnosis also serves as shorthand to enhance communication, research, surveillance, and reimbursement. The diagnosis of mental disorders is often believed to be more difficult than diagnosis of somatic, or general medical, disorders, since there is no definitive lesion,- laboratory test, or abnormality in brain tissue that can identify the illness. The diagnosis of mental disorders must rest with the patients' reports of the intensity and duration of symptoms, signs from their mental status examination, and clinician observation of their behavior including functional impairment. These clues are grouped together by the clinician into recognizable patterns known as syndromes. When the syndrome meets all the criteria for a diagnosis, it constitutes a mental disorder. Most mental health conditions are referred to as disorders, rather than as diseases, because diagnosis rests on clinical criteria. The term "disease" generally is reserved for conditions with known pathology (detectable physical change). The term "disorder," on the other hand, is reserved for clusters of symptoms and signs associated with distress and disability (i.e., impairment of functioning), yet whose pathology and etiology are unknown. The standard manual used for diagnosis of mental disorders in the United States is the Diagnostic and Statistical Manual of Mental Disorders. Most recently revised in 1994, this manual now is in its fourth edition (American Psychiatric Association, 1994, hereinafter cited in this report as DSM-IV). The first edition was published in 1952 by the American Psychiatric Association; subsequent revisions, which were made on the basis of field trials, analysis of data sets, and systematic reviews of the research literature, have sought to gain greater objectivity, diagnostic precision, and reliability. DSM-IV organizes mental disorders into 16 major diagnostic classes listed in Table 2-5. For each disorder within a diagnostic class, DSPUI;IV enumerates specific criteria for making the diagnosis. DSM-IV also.lists diagnostic "subtypes" for some disorders. A subtype is a subgroup within a diagnosis that confers greater specificity. DSM-IV is descriptive in its listing of symptoms and does not take a position about underlying causation. Table 2-5. Major Diagnostic Classes of Mental Disorders (DSM-IV1 Disorders usually first diagnosed in infancy, childhood, or adolescence Delerium, dementia, and amnestic and other cognitive disorders Mental disorders due to a general medical condition Substance-related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse-control disorders Adjustment disorders Personality disorders 44 DSM-IV and its predecessors* represent a "nioue approach to diagnosis by a professional field. No other sphere of health care has created ,"ch an extensive compendium of all of its Jisorders with explicit diagnostic criteria. The if'orld Health Organization's international CILIxSification ofDiseases (10th edition, 1992) is a valuable compendium of all diseases. Its mental health categories are expanded upon in DSM-IV. The ~,rternationaf C~assijication ofDiseases (ICD) is the official classification for mortality and morbidity statistics for all signatories to theU.N. Charter establishing the World Health Organization. ICD-9CM (9th edition, Clinical Xlodification, 1991) is still the official classification for the Health Care Financing Administration. Knowledge about diagnosis continues to evolve. Evolution in the diagnosis of mental disorders generally reflects greater understanding of disorders as well as the influence of social norms. Years ago, for instance, addiction to tobacco was not viewed as a disorder, but today it l'alls under the category of "Substance-Related Disorders." Although DSM-IV strives to cover all populations, it is not without limitations. The difficulties encountered in diagnosing mental disorders in children, older persons, and racial and ethnic minority groups are discussed later in this chapter and throughout this report. Diagnosis rests on clinician judgment about whether clients' symptom patterns and impairments of functioning meet diagnostic criteria. Cultural differences in emotional expression and social behavior can be misinterpreted as "impaired" if clinicians are not sensitive to the cultural context and meaning of exhibited symptoms, a topic discussed later in this chapter in Overview of Cultural Diversity and Mental Health Services. ' DSM-1 (American Psychiatric Association, 1952), DSM-II (Amerkan Psychiatric Association, 1968), DSM-III (American Psychiatric Association, 1979). and DSM-III-R (American Psychiatric Association, 1987). Epidemiology of Mental Illness Few families in the United States are untouched by mental illness. Determining just how many people have mental illness is one of the many purposes of the field of epidemiology. Epidemiology is the study of patterns of disease in the population. ,Among the key terms of this discipline, encountered throughout this report, are incidence, which refers to new cases of a condition which occur during a specified period of time, and prevalence, which refers to cases (i.e., new and existing) of a condition observed at a point in time or during a period of time.*According to current epidemiological estimates, at least one in five people has a diagnosable mental disorder during the course of a year (i.e., l-year prevalence). Epidemiological estimates have shifted over time because of changes in the definitions and diagnosis of mental health and mental illness. In the early 1950s the rates of mental illness estimated by epidemiologists were far higher than those of today. One study, for example, found 81.5 percent of the population of Manhattan, New York, to have had signs and symptoms of mental distress (Srole, 1962). This led the authors of the study to conclude that mental illness was widespread. However, other studies began to find lower rates when they used more restrictive definitions that reflected more contemporary views about mental illness. Instead of classifying anyone with signs and symptoms as being mentally ill, this more recent line of epidemiological research only identified people as mentally ill if they had a cluster of signs and symptoms that, when taken together, impaired people's ability to function (Pasamanick, 1959; Weissman et al., 1978). By 1978, the President's Commission on Mental Health (1978) concluded conservatively that the annual prevalence of specific mental disorders in the United States was about 15 percent. This figure comports with recent estimates of the extent of mental illness in the population. Even as this figure has become more sharply delineated, the older and larger estimates underscore the magnitude of mental distress in the The Fundamentals of Mental Health and Mental Illness 45 Mental Health: A Report of the Surgeon General population, which this report refers to as "mental health problems." Adults The current prevalence estimate is that about 20 percent of the U.S. population are affected by mental disorders during a given year. This estimate comes from two epidemiologic surveys: the Epidemiologic Catchment Area (ECA) study of the early 1980s and the National Comorbidity Survey (NCS) of the early 1990s. Those surveys defined mental illness according to the prevailing editions of the Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-III and DSM-III-R). The surveys estimate that during a 1 -year period, .22 to 23 percent of the U.S. adult population-or 44 million people -have diagnosable mental disorders, according to reliable, established criteria. In general, 19 percent of the adult U.S. population have a mental disorder alone (in 1 year); 3 percent have both mental and addictive disorders; and 6 percent have addictive disorders alone.3 Consequently, about 28 to 30 percent of the population have either a mental or addictive disorder (Regier et al., 1993b; Kessler et al., 1994). Table 2-6 summarizes the results synthesized from these two large national surveys. Individuals with co-occurring disorders (about 3 percent of the population in 1 year) are more likely to experience a chronic course and to utilize services than are those with either type of disorder alone. Clinicians, program developers, and policy- makers need to be aware of these high rates of comorbidity-about 15 percent of those with a mental disorder in 1 year (Regier et al., 1993a; Kessler et al., 1996). Based on data on functional impairment, it is estimated that 9 percent of all U.S. adults have the mental disorders listed in Table 2-6 and experience some significant functional impairment (National ' Although addictive disorders are included as mental disorders in the DSM classification system, the ECA and NCS distinguish between addictive disorders and (all other) mental disorders. Epidemiologic data in this report follow that convention. Advisory Mental Health Council [NAMHC], 1993). Most (7 percent of adults) have disorders that persist for at least 1 year (Regier et al., 1993b; Regier et al., in press). A subpopulation of 5.4 percent of adults is considered to have a "serious" mental illness (SMI) (Kessler et al., 1996). Serious .mental illness is a term defined by Federal regulations that generally applies to mental disorders that interfere with some area of social functioning. About half of those with SMI (or 2.6 percent of all adults) were identified as being even more seriously affected, that is, by having "severe and persistent" mental illness (SPMI) (NAMHC, 1993; Kessler et al., 1996). This category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive- compulsive disorder. These disorders and the problems faced by these special populations with SMI and SPMI are described further in subsequent chapters. Among those most severely disabled are the approximately 0.5 percent of the population who receive disability benefits for mental health- related reasons from the Social Security Administration (NAMHC, 1993). Children and Adolescents The annual prevalence of mental disorders in children and adolescents is not as well documented as that for adults. About 20 percent of children are estimated to have mental disorders with at least mild functional impairment (see Table 2-7). Federal regulations also define a sub-population of children and adolescents with more severe functional limitations, known as "serious emotional disturbance" (SED).4 Children and adolescents with SED number approximately 5 to 9 percent of children ages 9 to 17 (Friedman et al., 1996b). 4 The term "serious emotional disturbance" is used in a variety of Federal statutes in reference to children under the age of 18 with a diagnosable mental health problem that severely disrupts their ability to function socially. academically, and emotionally. The term does not signify any particular diagnosis; rather, it is a legal term that triggers a host of mandated services to meet the needs of these children. 46 The Fundamentals of Mental Health and Mental Illness Table 2-6. Best estimate l-year prevalence rates based on ECA and NCS, ages 18-54 4ny Anxiety Disorder 13.1 18.7 16.4 Simple Phobia 8.3 8.6 6.3 Social Phobia 2.0 7.4 2.0 Agoraphobia GAD (::E)* 3.7 4.9 3.4 3.4 Panic Disorder 1.6 1.6 OCD (kg 2.4 PTSD 3.6 3.6 .- ._ . . _` . .;hx.b& any Mood Disorder MD Episode Unipolar MD Dysthymia Bipolar I Bipolar II .I. .- ~ .",?>.4YFp .id`i'd. Schizophrenia Nonaffective Psychosis Somatization ASP Anorexia Nervosa Severe Cognitive Impairment 7.1 11.1 7.1 6.5 10.1 6.5 5.3 8.9 5.3 1.6 2.5 1.6 1.1 1.3 1.1 0.6 0.2 0.6 .I.*= .&.?: 1.3 1.3 0.2 0.2 0.2 - 0.2 2.1 - 2.1 0.1 0.1 1.2 - 1.2 Anv Disorder 19.5 23.4 21 .o `Numbers in parentheses indicate the prevalence of the disorder without any comorbidity. These rates were calculated using the NCS data for GAD and PTSD, and the ECA data for OCD. The rates were not used in calculating the any anxiety disorder and any disorder totals for the ECA and NCS columns. The unduplicated GAD and PTSD rates were added to the best estimate total for any anxiety disorder (3.3%) and any disorder (1.5%). "In developing best-estimate 1 -year prevalence rates from the two studies, a conservative procedure was followed that had previously been used in an independent scientific analysis comparing these two data sets (Andrews, 1995). For any mood disorder and any anxiety disorder, the lower estimate of the two surveys was selected, which for these data was the ECA. The best estimate rates for the individual mood and anxiety disorders were then chosen from the ECA only, in order to maintain the relationships between the individual disorders. For other disorders that were not covered in both surveys, the available estimate was used. Key to abbreviations: ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study; GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; MD, major depression; ASP, antisocial personality disorder. Source: D. Regier, W. Narrow, & D. Rae, personal communication, 1999 41 Mental Health: A Report of the Surgeon General Table 2-7. Children and adolescents ages 9 to 17 with mental or addictive disorders,* combined MECA sample Prevalence (%) Anxiety disorders 13.0 Mood disorders 6.2 Disruptive disorders 10.3 Substance use disorders 2.0 Any disorder 20.9 *Disorders include diagnosis-specific impairment and Child Global Assessment Scale ~70 (mild global impairment). Source: Shaffer et al., 1996 Not all mental disorders identified in childhood and adolescence persist into adulthood, even though the prevalence of mental disorders in children and adolescents is about the same as that for adults (i.e., about 20 percent of each age population). While some disorders do continue into adulthood, a substantial fraction of children and adolescents recover or ."grow out of' a disorder, whereas, a substantial fraction of adults develops mental disorders in adulthood. In short, the nature and distribution of mental disorders in young people are somewhat different from those of adults. Older Adults The annual prevalence of mental disorders among older adults (ages 55 years and older) is also not as well documented as that for younger adults. Estimates generated from the ECA survey indicate that 19.8 percent of the older adult population have a diagnosable mental disorder during a l-year period (Table 2-8). Almost 4 percent of older adults have SMI, and just under 1 percent has SPMI (Kessler et al., 1996); these figures do not include individuals with severe cognitive impairments such as Alzheimer's disease. Future Directions for Epidemiology The epidemiology of mental disorders is somewhat handicapped by the difficulty of identifying a "case" of a mental disorder. "Case" is an Table 2-9. Best estlmate prevalence rates based I I L on Epldemiolo@c Catchment Area, age 55+ Prevalence (%) 9ny Anxiety Disorder 11.4 Simple Phobia 7.3 Social Phobia 1 .o Agoraphobia 4.1 Panic Disorder 0.5 Obsessive-Compulsive Disorder 1.5 ?m Any Mood Disorder 4.4 Major Depressive Episode 3.8 Unipolar Major Depression 3.7 Dysthymia 1.6 Bipolar I 0.2 Bipolar II 0.1 Schizophrenia Somatization Antisocial Personality Disorder 0.0 Anorexia Nervosa Severe Cognitive Impairment Source: D. Regier, W. Narrow, & D. Rae, personal com- munication, 1999 epidemiological term for someone who meets the criteria for a disease or disorder. It is not always easy to establish a threshold for a mental disorder, particularly in light of how common symptoms of mental distress are and the lack of objective, physical symptoms. It is sometimes difficult to determine when a set of symptoms rises to the level of a mental disorder, a problem that affects other areas of health (e.g., criteria for certain pain syndromes). In many cases, symptoms are not of sufficient intensity or duration to meet the criteria for a disorder and the threshold may vary from culture to culture. Diagnosis of mental disorders is made on the basis of a multidimensional assessment that takes into account observable signs and symptoms of 48 The Fundamentals of Mental Health and Mental Illness illness, the course and duration of illness, response [o treatment. and degree of functional impairment. one Problem has been that there is no clearly ,,,easurable threshold for functional impairments. Efforts are currently under way in the epidemiology ,,f mental disorders to create a threshold, or agreed- uPon minimum level of functional limitation, that ,hould be required to establish a "case" (i.e., a clinically significant condition). Epidemiology reflecting the state of psychiatric nosology during the Past two decades has focused primarily on sbrmptom clusters and has not uniformly abplied-or, at times, even measured-the level of Jysfunction. Ongoing reanalyses of existing cpidemiological data are expected to yield better understanding of the rates of mental disorder and dysfunction in the population. Another limitation of contemporary mental health knowledge is the lack of standard measures of "need for treatment," particularly those which arc culturally appropriate. Such measures are at the heart of the public health approach to mental health. Current epidemiological estimates therefore cannot definitively identify those who are in need of treatment. Other estimates presented, in Chapter 6 indicate that some individuals with. mental disorders are in treatment and others are not; some are seen in primary care settings and others in specialty care. In the absence of valid measures of riced.. rates of disorder estimated in epidemiological surveys serve as an imperfect proxy for the need for care and treatment (Regier et al., in press). Subsequent sections of this report reveal the Population basis of our understanding of mental health. Where appropriate, the report discusses mental health and illness across the entire Population. At other times, the focus is on care in specialized mental health settings, primary health care, schools, the criminal justice system, and even the streets. A mainstream public health and Population-based perspective demands such a broad view of mental health and mental illness. Costs of Mental Illness The costs of mental illness are .exceedingly high. Although the question of cost is discussed more fully in Chapter 6, a few of the central findings are presented here. The direct costs of mental health services in the United States in 1996 totaled $69.0 billion. This figure represents 7.3 percent of total health spending. An additional $17.7 billion was spent on Alzheimer's disease and $12.6 billion on substance abuse treatment. Direct costs correspond to spending for treatment and rehabilitation nationwide. When economists calcblate the costs of an illness, they also strive to identify indirect costs. Indirect costs can be defined in different ways, but here they refer to lost productivity at the workplace, school, and home due to premature death or disability. The indirect costs of mental illness were estimated in 1990 at $78.6 billion (Rice & Miller, 1996). More than 80 percent of these costs stemmed from disability rather than death because mortality from mental disorders is relatively low. Overview of Etiology The precise causes (etiology) of most mental disorders are not known. But the key word in this statement is precise. The precise causes of most mental disorders-or, indeed, of mental health- may not be known, but the broad forces that shape them are known: these are biological, psycho- logical, and social/cultural factors. What is most important to reiterate is that the causes of health and disease are generally viewed as a product of the interplay or interaction between biological, psychological, and sociocultural factors. This is true for all health and illness, including mental health and mental illness. For instance, diabetes and schizophrenia alike are viewed as the result of interactions between biological, psychological, and sociocultural influences. With these disorders, a biological predisposition is necessary but not sufficient to explain their occurrence (Barondes, 1993). For other disorders, 49 Mental Health: A Report of the Surgeon General a psychological or sociocultural cause may be necessary, but again not sufficient. As described in the section on modern neuroscience, the brain and behavior are inextricably linked by the plasticity of the nervous system. The brain is the organ of mental function; psychological phenomena have their origin in that complex organ. Psychological and sociocultural phenomena are represented in the brain through memories and learning, which involve structural changes in the neurons and neuronal circuits. Yet neuroscience does not intend to reduce all phenomena to neurotransmission or to reinterpret them in a new language of synapses, receptors, and circuits. Psychological and sociocultural events.and phenomena continue to have meaning for mental health and mental illness. Much of the research that is presented in the remainder of this report draws on theories and investigations that predate the more modern view of integrative neuroscience. It is still meaningful, however, to speak of the interaction of biological and psychological and sociocultural factors in health and illness. That is where the overview of etiology begins-with the biopsychosocial model of disease, followed by an explanation of important terms used in the study of etiology. Then, against the backdrop of the introductory section on brain and behavior, the following sections address biological and psychosocial influences on mental health and mental illness, a separation that reflects the distinctive research perspectives of past decades. The overview of etiology draws to a close with a discussion of the convergence of biological and psychosocial approaches in the study of mental health and mental illness. Biopsychosocial Model of Disease The modern view that many factors interact to produce disease may be attributed to the seminal work of George L. Engel, who in 1977 put forward the Biopsychosocial Model of Disease (Engel, 1977). Engel's model is a framework, rather than a set of detailed hypotheses, for understanding health and disease. To many scientists, the model lacks sufficient specificity to make predictions about the given cause or causes of any one disorder. Scientists want to find out what specifically is the contribution of different factors (e.g., genes, parenting, culture, stressful events) and how they operate. But the purpose of. the biopsychosocial model is to take a broad view, to assert that simply looking at biological factors alone-which had been the prevailing view of disease at the time Engel was writing-is not sufficient to explain health and illness. According to Engel's `model, biopsychosocial factors are involved in the causes, manifestation, course, and outcome of health and disease, including mental disorders. The model certainly fits with common experience. Few people with a condition such as heart disease or diabetes, for instance, would dispute the role of stress in aggravating their condition. Research bears this out and reveals many other relationships between stress and disease (Cohen & Herbert, 1996; Baum & Posluszny, 1999). One single factor in isolation-biological, psychological, or social-may weigh heavily or hardly at all, depending on the behavioral trait or mental disorder. That is, the relative importance or role of any one factor in causation often varies. For example, a personality trait like extroversion is linked strongly. to genetic factors, according to identical twin studies (Plomin et al., 1994). Similarly, schizophrenia is linked strongly to genetic factors, also according to twin studies (see Chapter 4). But this does not mean that genetic factors completely preordain or fix the nature of the disorder and that psychological and social factors are unimportant. These social factors modify expression and outcome of disorders. Likewise, some mental disorders, such as post-traumatic stress disorder (PTSD), are clearly caused by exposure to an extremely stressful event, such as rape, combat, natural disaster, or concentration camp (Yehuda, 1999). Yet not everyone develops PTSD after such exposure. On average, about 9 50 i,crccnt do (Breslau et al., 1998), but estimates are higher for particular types of trauma. For women ,, ho are victims of crime, one study found the ptcvalence of PTSD in a representative sample of I\ omen to be 26 percent (Resnick et al., 1993). The likelihood of developing PTSD is related to p,-rtrauma vulnerability (in the form of genetic, biological. and personality factors), magnitude of the stressful event, preparedness for the event, and rl,r quality of care after the event (Shalev, 1996). The relative roles of biological, psychological, or social factors also may vary across individuals and across stages of the life span. In some people, for example, depression arises primarily as a result of exposure to stressful life events, whereas in others the foremost cause of depression is genetic predisposition. Understanding Correlation, Causation, and Consequences (\ny discussion of the etiology of mental health and tncntal illness needs to distinguish three key terms: correlation, causation, and consequences. These terms are often confused. All too frequently a biological change in the brain (a lesion) is purported to be the "cause" of a mental'disorder, based on finding an association between the lesion and a mental disorder. The fact is that any simple association-or correlation-cannot and does not, by itself, mean causation. The lesion could be a correlate, a cause of, or an effect of the mental disorder. When researchers begin to tease apart etiology, they usually start by noticing correlations. A correlation is an association or linkage of two (or more) events. A correlation simply means that the events are linked in some way. Finding a correlation between stressful life events and depression would prompt more research on causation. Does stress cause depression? Does depression cause stress? Or are they both caused by an unidentified factor? These would be the questions guiding research. But, with correlational The Fundamentals of Mental Health and Mental Illness research, several steps are needed before causation can be established. If a correlational study shows that a stressful event is associated with an increased probability for depression and that the stress usually precedes depression's onset, then stress is called a "risk factor" for depression.5 Risk factors are biological, psychological, or sociocultural variables that increase the probability for developing a disorder and antedate its onset (Garmezy, 1983; Werner & Smith, 1992; Institute of Medicine [IOM], 1994a). For each mental disorder, there are likely to be multiple risk factors, which are woven together in a complex chain of causation (IOM, 1994a). Some risk factors may carry more weight than others, and the interaction of risk factors may be additive or synergistic. Establishing causation of mental health and mental illness is extremely difficult, as explained in Chapter 1. Studies in the form of randomized, controlled experiments provide the strongest evidence of causation. The problem is that experimental research in humans may be logistically, ethically, or financially impossible. Correlational research in humans has thus provided much of what is known about the etiology of mental disorders. Yet correlational research is not as strong as experimental research in permitting inferences about causality. The establishment of a cause and effect relationship requires multiple studies and requires judgment about the weight of all the evidence. Multiple correlational studies can be used to support causality, when, for example, evaluating the effectiveness of clinical treatments (Chambless et al., 1996). But, when studying etiology, correlational studies are, if possible, best combined with evidence of biological plausibility s Chapter 4 contains a fuller discussion of the relationship between stress and depression. In common parlance, stress refers either to the stressful event or to the individual's response to the event. However, mental health professionals distinguish the two by referring to the external events as the "stressor" (or stressful life event) and to the individual's response as the "stress response." 51 Mental Health: A Report of the Surgeon General (IOM, 1994b).6 This means that correiational findings should fit with biological, chemical, and physical findings about mechanisms of action relating to cause and effect. Biological plausibility is often established in animal models of disease. That is why researchers seek animal models in which to study causation. In mental health research, there are some animal models-such as for anxiety and hyperactivity-but a major problem is the difficulty of finding animal models that simulate what is often uniquely human functioning. The search for animal models, however, is imperative. Consequences are defined as the later outcomes of a disorder. For example, the most serious consequence of depression in older people is increased mortality from either suicide or medical illness (Frasure-Smith et al., 1993, 1995; Conwell, 1996; Penninx et al., 1998). The basis for this relationship is not fully known. The relationship between depression and suicide in adolescents is presented in Chapter 3. Putting this all together, the biopsychosocial model holds that biological, psychological, or social factors may be causes, correlates, and/or consequences in relation to menial health and mental illness. A stressful life event, such as receiving the news of a diagnosis of cancer, offers a graphic example of a psychological event that causes immediate bi,ological changes and later has psychological, biological, and social consequences. When a patient receives news of the cancer diagnosis, the brain's sensory cortex simultan- eously registers the information (a correlate) and sets in motion biological changes that cause the heart to pound faster. The patient may experience an almost immediate fear of death that may later escalate to anxiety or depression. This certainly has been established for breast cancer patients (Farragher, 1998). Anxiety and depression are, in ' Other types of information used to establish cause and effect relationships are the strength and consistency of the association, time sequence information, dose-response relationships, and disappearance of the effect when the cause is removed. this case, consequences of the cancer diagnosis,' although the exact mechanisms are not understood. Being anxious or depressed may prompt further changes in behavior, such as social withdrawal. So there may be social consequences to the diagnosis as well. This example is designed to lay out some of the complexity of the biopsychosocial model applied to mental health and mental illness. Biological Influences on Mental Health and Mental Illness There are far-reaching biological and physical influences on mental health and mental illness. The major categories are genes, infections, physical trauma, nutrition, hormones, and toxins (e.g., lead). Examples have been noted throughout Chapter 1 and earlier in this chapter. This section focuses on the first two categories-genes and infections-for these are among the most exciting and intensive areas of research relating to biological influences on mental health and mental illness. The Genetics of Behavior and Mental illness That genes influence behavior, normal and abnormal, has long been established (Plomin et al., 1997). Genes influence behavior across the animal spectrum, from the lowly fruitfly all the way to humans. Sorting out which genes are involved and determining how they influence behavior present the greatest challenge. Research suggests that many mental disorders arise in part from defects not in single genes, but in multiple genes. However, none of the genes has yet been pinpointed for common mental disorders (National Institute of Mental Health [NIMH], 1998). The human genome contains approximately 80,000 genes that occupy approximately 5 percent of the DNA sequences of the human genome. By the spring of 2000, the human genome project will have provided an initial rough draft version of the entire sequence of the human genome, and in the ' Anxiety and depression may in some cases be caused by hormonal changes related to the tumor itself. 52 The Fundamentals of Mental Health and Mental Illness ensuing years, gaps in the sequence will be closed, errors will be corrected, and the precise boundaries \,f genes will be identified. ln parallel, clinical medicine is studying the ;tgcregation of human disease in families. This se c'ffort includes the study of mental illness, most notably schizophrenia, bipolar disorder (manic depressive illness), early onset depression, autism, mention-deficit/hyperactivity disorder, anorexia uervosa. panic disorder, and a number of other mental disorders (NIMH, 1998). From studying how these disorders run in families, and from initial molecular analyses of the genomes of these families, we have learned that heredity-that `is, genes-plays a role in the transmission of vulnerability of all the aforementioned disorders from generation to generation. But we have also learned that the transmission of risk is not simple. Certain human diseases such ;LS Huntington's disease and cystic fibrosis result from the transmission of a mutation-that is, a rlclcteriously altered gene sequence-at one location in the human genome. In these diseases, a. single mutation has everything to say about whether one will get the illness. The transmission of a trait due to a single gene in the human genome is called hlendelian transmission, after the Austrian monk, (lrcgor Mendel, who was the first to develop principles of modern genetics and who studied traits due to single genes. When a single gene determines the presence or absence of a disease or other trait, genes are rather easy to discover on the hasis of modern methods. Indeed, for almost all hlrndelian disorders across medicine that affect more than a few people, the genes already have heen identified. ln contrast to Mendelian disorders, to our knowledge, all mental illnesses and all normal variants of behavior are genetically complex. What this means is that no single gene or even a combination of genes dictates whether someone \vill have an illness or a particular behavioral trait. Rather. mental illness appears to result from the interaction of multiple genes that confer risk, and this risk is converted into illness by the interaction of genes with environmental factors. The implications for science are, first, that no gene is equivalent to fate for mental illness. This gives us hope that modifiable environmental risk factors can eventually be identified and become targets for prevention efforts. In addition, we recognize that genes, while significant in their aggregate contribution to risk, may each contribute only a small increment, and, therefore, will be difficult to discover. As a result, however, of the Human Genome Project, we will know the sequence of each human gene and the common variants for each gene throughout the human race. With this information, combined with modern technologies, we will in the coming years identify genes that confer risk of specific mental illnesses. This information will be of the highest importance for several reasons. First, genes are the blueprints of cells. The products of genes, proteins, work together in pathways or in building cellular structures, so that finding variants within genes will suggest pathways that can be targets of opportunity for the development of new therapeutic interventions. Genes will also be important clues to what goes wrong in the brain when a disease occurs. For example, once we know that a certain gene is involved in risk of a particular mental illness such as schizophrenia or autism, we can ask at what time during the development of the brain that particular gene is active and in which cells and circuits the gene is expressed. This will give us clues to critical times for intervention in a disease process and information about what it is that goes wrong. Finally, genes will provide tools for those scientists who are searching for environmental risk factors. Information from genetics will tell us at what age environmental cofactors in risk must be active, and genes will help us identify homogeneous populations for studies of treatment and of prevention. Heritability refers to how much genetics con- tributes to the variation of a disease or trait in a population at a given point in time (Plomin et al., Mental Health: A Report of the Surgeon General 1997). Once a disorder is established as running in families, the next step is to determine its heritability (see below), then its mode of transmission, and, lastly, its location through genetic mapping (Lombroso et al., 1994). One powerful method for estimating heritability is through twin studies.* Twin studies often compare the frequency with which identical versus fraternal twins display a disorder. Since identical twins are from the same fertilized egg, they share the exact genetic inheritance. Fraternal twins are from separate eggs and thereby share only 50 percent of their genetic inheritance. If a disorder is heritable, identical twins should have a higher .rate of concordance-the expression of the trait by both members of a twin pair-than fraternal twins. Such studies, however, do not furnish information about which or how many genes are involved. They just can be used to estimate heritability. For example, the heritability of bipolar disorder, according to the most rigorous twin study, is about 59 percent, although other estimates vary (NIMH, 1998). The heritability of schizophrenia is estimated, on the basis of twin studies, at a somewhat higher level (NIMH, 1998). Even with a high level of heritability, however, it is essential to point out that environmental factors (e.g., psychosocial environment, nutrition, health care access) can play a significant role in the severity and course of a disorder. Another point is that environmental factors may even protect against the disorder developing in the first place. Even with the relatively high heritabili- ty of schizophrenia, the median concordance rate among identical twins is 46 percent' (NIMH, 1998), meaning that in over half of the cases, the second * Establishing that a disorder runs in families could suggest environmental and/or genetic influences because families share genes and environment. Comparing identical versus fraternal twins assumes that their shared environments are about equal, thereby providing insight about genetic influences. Such comparisons are further enhanced by studies of twins (identical vs. fraternal) separated at birth and adopted by different families. 9 The median concordance rate for identical twins is only 14 percent (NIMH, 1998). twin does not manifest schizophrenia even though he or she has the same genes as the affected twin. This implies that environmental factors exert a significant role in the onset of schizophrenia. Infectious Influences It has been known since the early part of the 20th century that infectious agents can penetrate into the brain where they can cause mental disorders. A highly common mental disorder of unknown etiology at the turn of the century, termed "general paresis," turned out to be a late manifestation of syphilis. The sexually transmitted infectious agent-Treponema pallidurn-first caused symptoms in reproductive organs and then, sometimes years later, migrated to the brain where it led to neurosyphilis. Neurosyphilis was manifest by neurological deterioration (including psychosis), paralysis, and later death. With the wide availability of penicillin after World War II, neurosyphilis was virtually eliminated (Barondes, 1993). Neurosyphilis may be thought of as a disease of the past (at least in the developed world), but dementia associated with infection by the human immunodeficiency virus (HIV) is certainly not. HIV-associated dementia continues to encumber HIV-infected individuals worldwide. HIV infection penetrates into the brain, producing a range of progressive cognitive and behavioral impairments. Early symptoms include impaired memory and concentration, psychomotor slowing, and apathy. Later symptoms, usually appearing years after infection, include global impairments marked by mutism, incontinence, and paraplegia (Navia et al., 1986). The prevalence of HIV-associated dementia varies, with estimates ranging from 15 percent to 44 percent of patients with HIV infection (Grant et al., 1987; McArthur et al., 1993). The high end of this estimate includes patients with subtle neuropsychological abnormalities. What is remarkable about HIV-associated dementia is that it appears to be caused not by direct infection of neurons, but by infection of immune cells known as 54 The Fundamentals of Mental Health and Mental Illness lnacrophages that enter the brain from the blood. The macrophages indirectly cause dysfunction and death in nearby neurons by releasing soluble toxins , Epstein & Gendelman, 1993). Besides HIV-associated dementia and neurosyphilis, other mental disorders are caused by infectious agents. They include herpes simplex encephalitis, measles encephalomyelitis, rabies encephalitis, chronic meningitis, and subacute ,clerosing panencephalitis (Kaplan & Sadock, 1998). More recently, research has uncovered an infectious etiology to one form of obsessive- compulsive disorder, as explained below. PANDAS ln the late 198Os, it was discovered that some children with obsessive-compulsive disorder (OCD) experienced a sudden onset of symptoms soon after ;I streptococcal pharyngitis (Garvey et al., 1998). The symptoms were classic for OCD-concerns about contamination, spitting compulsions, and extremely excessive hoarding-but the abrupt onset was unusual. Further study of these children led to the identification of a new classification of OCD called PANDAS. This acronym stands for pediatric :tutoimmune neuropsychiatric disorders associated with streptococcal infection. PANDAS are distinct from classic cases of OCD because of their episodic clinical course marked by sudden symptom exacerbation linked to streptococcal infection, among other unique features. The exacerbation of symptoms is correlated with a rise in levels of antibodies that the child produces to fight the strep infection. Consequently, researchers proposed that PANDAS are caused by antibodies against the strep infection that also manage to attack the basal ganglia region of the child's brain (Garvey et al., 1998). In other words, the strep infection triggers the child's immune system to develop antibodies, which, in turn, may attack the child's brain, leading to obsessive and compulsive behaviors. Under this proposal, the strep infection does not directly induce the condition; rather, it may do so indirectly by triggering antibody formation. How the antibodies are so damaging to a discrete region of the child's brain and how this attack ignites OCD-like symptoms are two of the fundamental questions guiding research. Psychosocial Influences on Mental Health and Mental Illness This chapter thus far has highlighted some of the psychosocial influences on mental health and mental illness. Stressful life eyents, affect (mood and level of arousal), personality, and gender are prominent psychological influences. Social influences include parents, socioeconomic status, racial, cultural, and religious background, and interpersonal relationships. These psychosocial influences, taken individually or together, are integrated into many chapters of this report in discussions of epidemiology, etiology, risk factors, barriers to treatment, and facilitators to recovery. Since these psychosocial influences are familiar to the general reader, detailed description of each is beyond the scope of this section (with the exception of cultural influences, which are discussed in the Overview of Cultural Diversity and Mental Health Services section). Instead, this section summarizes the sweeping theories of individual behavior and personality that inspired a vast body of psychosocial research: psychodynamic theories, behaviorism, and social learning theories. The therapeutic strategies that arose from these theories, and modifications necessary to make them relevant to the changing demography of the U.S. population, are discussed in a later section, Overview of Treatment. Psychodynamic Theories Psychodynamic theories of personality assert that behavior is the product of underlying conflicts over which people often have scant awareness. Sigmund Freud (1856-1939) was the towering proponent of psychoanalytic theory, the first of the 20th-century psychodynamic theories. Many of Freud's Mental Health: A Report of the Surgeon General followers pioneered their own psychodynamic theories, but this section covers only psychoanalytic theory. A brief discussion of Freud's work contributes to an historical perspective of mental health theory and treatment approaches. Freud's theory of psychoanalysis holds two major assumptions: (1) that much of mental life is unconscious (i.e., outside awareness), and (2) that past experiences, especially in early childhood, shape how a person feels and behaves throughout life (Brenner, 1978). Freud's structural model of personality divides the personality into three parts-the id, the ego, and the superego. The id is the unconscious part that is the cauldron of raw drives, such as for sex or aggression. The ego, which -has conscious and unconscious elements, is the rational and reasonable part of personality. Its role is to maintain contact with the outside world in order to help keep the individual in touch with society. As such, the ego mediates between the conflicting tendencies of the id and the superego. The latter is a person's conscience that develops early in life and is learned from parents, teachers, ahd others. Like the ego, the superego has conscious and unconscious elements (Brenner, 1978). When all three parts of the personality are in dynamic equilibrium, the individual is thought to be mentally healthy. However, according to psychoanalytic theory, if the ego is unable to mediate between the id and the superego, an imbalance would occur in the form of psychological distress and symptoms of mental disorders. Psychoanalytic theory views symptoms as important only in terms of expression of underlying conflicts between the parts of personality. The theory holds that the conflicts must be understood by the individual with the aid of the psychoanalyst who would help the person unearth the secrets of the unconscious. This was the basis for psychoanalysis as a form of treatment, as explained later in this chapter. 56 Behaviorism and Social learning Theory Behaviorism (also called learning theory) posits that personality is the sum of an individual's observable responses to the outside world (Feldman, 1997). As charted by J. B. Watson and h. F. Skinner in the early part of the 20th century, behaviorism stands at loggerheads with psychodynamic theories, which strive to understand underlying conflicts. Behaviorism rejects the existence of underlying conflicts and an unconscious. Rather, it focuses on observable, overt behaviors that are' learned from the environment (Kazdin, 1996, 1997). Its application to treatment of mental problems, which is discussed later, is known as behavior modification. Learning is seen as behavior change molded by experience. Learning is accomplished largely through either classical or operant conditioning. Classical conditioning is grounded in the research of Ivan Pavlov, a Russian physiologist. It explains why some people react to formerly neutral stimuli in their environment, stimuli that previously would not have elicited a reaction. Pavlov's dogs, for example, learned to salivate merely at the sound of the bell, without any food in sight. Originally, the sound of the bell would not have elicited salvation. But by repeatedly pairing the sight of the food (which elicits salvation on its own) with the sound of the bell, Pavlov taught the dogs to salivate just to the sound of the bell by itself. Operant conditioning, a process described and coined by B. F. Skinner, is a form of learning in which a voluntary response is strengthened or attenuated, depending on its association with positive or negative consequences (Feldman, 1997). The strengthening of responses occurs by positive reinforcement, such as food, pleasurable activities, and attention from others. The attenuation or discontinuation of responses occurs by negative reinforcement in the form of removal of a pleasurable stimulus. Thus, human behavior is shaped in a trial and error way through positive and negative reinforcement, without any reference to inner conflicts or perceptions. What goes on inside The Fundamentals of Mental Health and Mental Illness the individual is irrelevant, for humans are equated \vith "black boxes." Mental disorders represented ,,,llladaptive behaviors that were learned. They Could be unlearned through behavior modification ,hehavior therapy) (Kazdin, 1996; 1997). The movement beyond behaviorism was sussion of heritability). Yet even with the most l,ighlY heritable traits or conditions, identical twins ,( lro share the same genetic endowment display ,n;trked differences. Identical twins, for example, ;,rc concordant for schizophrenia in 46 percent of ll;iirs (NIMH, 1998), meaning that more than 50 llcrcent of pairs are not concordant. Something yet utlkt~own about the environment protects against the development of schizophrenia in genetically itlcntical individuals (Plomin, 1996). How do nature and nurture interact? This ilucstion cannot be directly answered by twin \tudies. Animal models have proven to be fertile IFround for study of the mechanisms-at the ? niolecular and cellular level-by which nature and nurture interact. As reviewed earlier, research in different animal models has established that the environment can alter the structure andfunction of the central nervous system (Baily & Kandel, 1993). This holds true not only during early development, but also into adulthood. Nurture influences nature, right down to detectable changes in the brain. During development of the nervous system, each neuron forms myriad intricate synaptic connections with other neurons, the outcome of the interaction of genes and the environment described above. In this case, the environment is a very general term-it denotes the local extracellular environment surrounding the growing neuron, as well as what we traditionally think of as the environment (sensory environment, psychosocial environment, diet, etc.). When a neuron forms a synapse with its target cell, the pattern of activity, usually furnished by external environmental stimulation, strengthens or weakens the developing synapse. Only strengthened synaptic connections survive early development to form enduring connections, while weakened synaptic connections are eliminated (Shatz, 1993; Kandel et al., 1995). For example, kittens deprived of visual experience early in life sustain permanent disruption to synapses in parts of their visual cortex (Hubel & Wiesel, 1970). Later in the course of development, established patterns of connections still can be altered by the environment-through learning. Studies in a variety of animal models have found that certain forms of learning lead to changes in the structure and function of neurons. With long-term . memory-the long-term storage of learned information-these changes take the form of an enhanced number of synaptic connections and increased gene expression (Kandel et al., 1995). Increased gene expression appears to be for synthesis of new proteins needed for the structural changes occurring at the synapse (Bailey & Kandel, 1993). Researchers continue to probe for changes in the brain associated with mental disorders. They have found, for instance, that repeated stress from the environment affects the hippocampus, an area of the brain located deep within the cerebral hemispheres. Research in animals has shown that repeated stress triggers atrophy of dendrites of certain types of neurons in a segment of the hippocampus (Sapolsky, 1996; McEwen, 1998). Similarly, imaging studies in humans suggest that stress-related disorders (e.g., post-traumatic stress disorder) induce possibly irreversible atrophy of the hippocampus (McEwen & Magarinos, 1997). Anxiety disorders also alter neuroendocrine systems (Sullivan et al., 1998). These are some of the tantalizing ways in which nurture influences nature. The mental health field is far from a complete understanding of the biological, psychological, and sociocultural bases of development, but develop- pment clearly involves interplay among these influences. Understanding the process of develop- ment requires knowledge, ranging from the most fundamental level-that of gene expression and The Fundamentals of Mental Health and Mental Illness 61 Mental Health: A Report of the Surgeon General interactions between molecules and cells-all the way up to the highest levels of cognition, memory, emotion, and language. The challenge requires integration of concepts from many different disciplines. A fuller understanding of development is not only important in its own right, but it is expected to pave the way for our ultimate understanding of mental health and mental illness and how different factors shape their expression at different stages of the life span. Overview of Prevention The field of public health has long recognized the imperative of prevention to contain a major health problem (IOM, 1,988). The principles of pre- vention were first applied to infectious diseases in the form of mass vaccination, water safety, and other forms of public hygiene. As successes amassed, prevention came to be applied to other areas of health, including chronic diseases (IOM, 1994a). A landmark report published by the Institute of Medicine in 1994 extended the concept of prevention to mental disorders (IOM, 1994a). Reducing Risks for Mental Disorders evaluated the body of research on the prevention of mental disorders, offered new definitions of prevention, and provided recommendations on Federal policies and programs, among other goals. Preventing an illness from occurring is inherently better than having to treat the illness after its onset. In many areas of health, increased understanding of etiology and the role of risk and protective factors in the onset of health problems has propelled prevention. In the mental health field, however, progress has been slow because of two fundamental and interrelated problems: for most major mental disorders, there is insufficient understanding about etiology and/or there is an inability to alter the known etiology of a particular disorder. While these have stymied the develop- ment of prevention interventions, some successful strategies have emerged in the absence of a full understanding of etiology. Rigorous scientific trials have documented successful prevention programs in such areas as dysthymia and major depressive disorder (Munoz et al., 1987; Clarke et al., 1993, conduct problems (Berrento-Clement et al., 1984), and risky behaviors leading to HIV infection (Kalichman et al., in press) and low birthweight babies (Olds et al., 1986). Much progress also has been made to prevent the occurrence of lead poisoning, which, if unchecked, can lead to serious and persistent cognitive deficits in children (Centers for Disease Control and Prevention, 1991; Pirkle et al., 1994). Lastly, historical milestones' in prevention of mental illness led to the successful eradication of neurosyphilis, pellagra, and measles encephalo- myelitis (measles invasion of the brain) in the developed world. Definitions of Prevention The term "prevention" has different meanings to different people. It also has different meanings to different fields of health. The classic definitions used in public health distinguish between primary prevention, secondary prevention, and tertiary prevention (Commission on Chronic Illness, 1957). Primary prevention is the prevention of a disease before it occurs; secondary prevention is the prevention of recurrences or exacerbations of a disease that already has been diagnosed; and tertiary prevention is the reduction in the amount of disability caused by a disease to achieve the highest level of function. The Institute of Medicine report on prevention identified problems in applying these definitions to the mental health field (IOM, 1994a). The problems stemmed mostly from the difficulty of diagnosing mental disorders and from shifts in the definitions of mental disorders over time (see Diagnosis of Mental Illness). Consequently, the Institute of Medicine redefined prevention for the mental health field in terms of three core activities: prevention, treatment, and maintenance (IOM, 1994a). Prevention, according to the IOM report, is similar to the classic concept of primary prevention 62 t'rc,lll public health: it refers to interventions to ,\ard off the initial onset of a mental disorder. Ire,tment refers to the identification of individuals ,t irh mental disorders and the standard treatment tar those disorders, which includes interventions to reduce the likelihood of future co-occurring disorders. And maintenance refers to interventions ,llat are oriented to reduce relapse and recurrence ;,,,d to provide rehabilitation. (Maintenance incorporates what the public health field tmditionally defines as some forms of secondary aIld all forms of tertiary prevention.) The Institute of Medicine's new definitions .of prevention have been very important in conceptualizing th'e nature of prevention activities for mental disorders; however, the terms have not yet been universally adopted by mental health rusearchers. As a result, this report strives to use the terms employed by the researchers themselves. To avoid confusion, the report furnishes the rclcvant definition along with study descriptions. When the term "prevention" is used in this report withour a qualifying term, it refers to the prevention of the initial onset of a mental disorder or emotional or behavioral problem,. including prevention of comorbidity. First onset corresponds to the initial point in time when an individual's mental health problems meet the full criteria for a diagnosis of a mental disorder. Risk Factors and Protective Factors The concepts of risk and protective factors, risk reduction, and enhancement of protective factors (also sometimes referred to as fostering resilience) are central to most empirically based prevention Programs. Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected at random from the general population, will develop a disorder (Garmezy, 1983; Werner & Smith, 1992; TOM, 1994a). TO qualify as a risk factor the variable must antedate the onset of the disorder. Yet risk factors are not static. They can change in relation to a The Fundamentals of Mental Health and Mental Illness developmental phase or a new stressor in one's life, and they can reside within the individual, family, community, or institutions. Some risks such as gender and family history are fixed; that is, they are not malleable to change. Other risk factors such as lack of social support, inability to read, and exposure to bullying can be altered by strategic and potent interventions (Coie & Krehbiel, 1984; Silverman, 1988; Olweus, 1991; Kellam & Rebok, 1992). Current research is focusing on the interplay between biological risk factors and psychosocial risk factors and how they can be modified. As explained earlier, even with' a highly heritable condition such as schizophrenia, concordance studies show that in over half of identical twins, the second twin does not have schizophrenia. This suggests the possibility of modifying the environment to eventually prevent the biological risk factor (i.e., the unidentified genes that contribute to schizophrenia) from being expressed. Prevention not only focuses on the risks associated with a particular illness or problem but also on protective factors. Protective factors improve a person's response to some environmental hazard resulting in an adaptive outcome (Rutter, 1979). Such factors, which can reside with the individual or within the family or community, do not necessarily foster normal development in the absence of risk factors, but they may make an appreciable difference on the influence exerted by risk factors (IOM, 1994a). There is much to be learned in the mental health field about the role of protective factors across the life span and within families as well as individuals. The potential for altering these factors in intervention studies is enormous. The construct of "resilience" is related to the concept of protective factors, but it focuses more on the ability of a single individual to withstand chronic stress or recover from traumatic life events. There are many different perceptions of what constitutes resilience or "competence," another related term. Despite the increasing popularity of these ideas, "virtually no intervention 63 Mental Health: A Report of the Surgeon General studies have been conducted that test the outcomes of resilience variables" (Grover, 1998). Preventive researchers use risk status to identify populations for intervention, and then they target risk factors that are thought to be causal and malleable and target protective factors that are to be enhanced. If the interventions are successful, the amount of risk decreases, protective factors increase, and the likelihood of onset of the potential problem also decreases. The risks for onset of a disorder are likely to be somewhat different from the risks involved in relapse of a previously diagnosed condition. This is an important distinction because at-risk terminology is used throughout the mental health intervention spectrum. The optimal treatment protocol for an individual with a serious mental condition aims to reduce the length of time the disorder exists, halt a progression of severity, and halt the recurrence of the original disorder, or if not possible, to increase the length of time between episodes (IOM, 1994a). To do this requires an assessment of the individual's specific risks for recurrence. Many mental health problems, especially in childhood, share some of the same risk factors for initial onset, so targeting those factors can result in positive outcomes in multiple areas. Risk factors that are common to many disorders include individual factors such as neurophysiological deficits, difficult temperament, chronic physical illness, and below-average intelligence; family factors such as severe marital discord, social disadvantage, overcrowding or large family size, paternal criminality, maternal mental disorder, and admission into foster care; and community factors such as living in an area with a high rate of disorganization and inadequate schools (IOM, 1994a). Also, some individual risk factors can lead to a state of vulnerability in which other risk factors may have more effect. For example, low birthweight is a general risk factor for multiple physical and mental outcomes; however, when it is combined with a high-risk social environment, it more consistently has poorer outcomes (McGauhey et al., 1991). The accumulation of risk factors usually increases the likelihood of onset of disorder, but the presence of protective factors can attenuate this to varying degrees. The concept of accumulation of risks in pathways that accentuate other risks has led prevention researchers to the concept of "breaking the chain at its weakest links" (Robins, 1970; IOM, 1994a). In other words, some of the risks, even though they contribute significantly to onset, may be less malleable than others to intervention. The preventive strategy is to change the risks that are most easily and quickly amen$ble to intervention. For example, it may be easier to prevent a child from being disruptive and isolated from peers by altering his or her classroom environment and increasing academic achievement than it is to change the home environment where there is severe marital discord and substance abuse. Because mental health is so intrinsically related to all other aspects of health, it is imperative when providing preventive interventions to consider the interactions of risk and protective factors, etiological links across domains, and multiple outcomes. For example, chronic illness, unemployment, substance abuse, and being the victim of violence can be risk factors or mediating variables for the onset of mental health problems (Kaplan et al., 1987). Yet some of the same factors also can be related to the consequences of mental health problems (e.g., depression may lead to substance abuse, which in turn may lead to lung or liver cancer). Overview of Treatment Introduction to Range of Treatments Mental disorders are treatable, contrary to what many think.12 An armamentarium of efficacious treatments is available to ameliorate symptoms. In I2 About 40 percent of those surveyed thought that they "didn't think anyone could help" as a reason for not seeking mental health treatment (Sussman et al., 1987). 64 The Fundamentals of Mental Health and Mental Illness t`a,.t. for most mental disorders, there is generally not just one but a range of treatments of proven CificXv. Most treatments fall under two general i2tegories. psychosocial and pharmacologicaLi \loreover. the combination of the two-known as ,nultimodal therapy-can sometimes be even more