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