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National Institutes of Health Substance Abuse and Mental Health Services Administration |
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. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof), which are associated with distress and/or impaired functioning and spawn a host of human problems that may include disability, pain, or death. Mental illness is the term that refers collectively to all diagnosable mental disorders.
Mental disorders generate an immense public health burden of disability. The World Health Organization, in collaboration with the World Bank and Harvard University, has determined the “burden of disability” associated with the whole range of diseases and health conditions suffered by peoples throughout the world. A striking finding of the landmark Global Burden of Disease study is that the impact of mental illness on overall health and productivity in the United States and throughout the world often is profoundly underrecognized. In established market economies such as the United States, mental illness is on a par with heart disease and cancer as a cause of disability.[1] Suicide—a major public health problem in the United States—occurs most frequently as a consequence of a mental disorder.
Mental disorders occur across the lifespan, affecting persons of all racial and ethnic groups, both genders, and all educational and socioeconomic groups. In the United States approximately 40 million people aged 18 to 64 years, or 22 percent of the population, had a diagnosis of mental disorder alone (19 percent) or of a co-occurring mental and addictive disorder in the past year.[2], [3], [4] At least one in five children and adolescents between age 9 and 17 years has a diagnosable mental disorder in a given year.[5] Mental and behavioral disorders and serious emotional disturbances (SEDs) in children and adolescents can lead to school failure, alcohol or illicit drug use, violence, or suicide.[6], [7], [8] About 5 percent of children and adolescents are extremely impaired by mental, behavioral, and emotional disorders.[9] In later life, the majority of people aged 65 years and older cope constructively with the changes associated with aging and maintain mental health, yet an estimated 25 percent of older people (8.6 million) experience specific mental disorders, such as depression, anxiety, substance abuse, and dementia, that are not part of normal aging. Alzheimer’s disease strikes 8 to 15 percent of people over age 65 years,[10] with the number of cases in the population doubling every 5 years of age after age 60 years. Alzheimer’s disease is thought to be responsible for 60 to 70 percent of all cases of dementia and is one of the leading causes of nursing home placements.[11]
Mental disorders vary in severity and in their impact on people’s lives. Mental disorders—such as schizophrenia, major depression and manic depressive or bipolar illness, and obsessive-compulsive disorder and panic disorder—can be enormously disabling.
| n | Schizophrenia will affect more than 2 million people in the United States in 1 year.3 The disorder tends to follow a long-term course, although the severity of symptoms may wax and wane. With modern treatments, increasing numbers of persons with schizophrenia can and do view recovery as an achievable goal. |
| n | Affective disorders, which encompass major depression and manic depressive illness, constitute a second category of severe mental illness. The World Health Organization found major depression to be the leading cause of disability among adults in developed nations such as the United States.1 About 6.5 percent of women and 3.3 percent of men will have major depression in any year. Manic depressive illness affects around 1 percent of adults, with comparable rates of occurrence in men and women. A high rate of suicide is associated with such mood disorders.[12] |
| n | Anxiety disorders encompass several discrete conditions, including panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and phobia. More common than other mental disorders, anxiety disorders affect as many as 19 million people in the United States annually.[13] |
Modern treatments for mental disorders are highly effective, with a variety of treatment options available for most disorders; there is no “one size fits all” treatment. Similarly, there exists today a diverse array of treatment settings, and a person may have the option of selecting a setting based on health care coverage, the clinical needs associated with a particular type or stage of illness, and personal preference.
Prevention scientists have developed, tested, and structured preventive interventions against depression, conduct disorder, and other adverse outcomes in high-risk groups of children. When applied with fidelity, preventive interventions can decrease risk of onset or delay onset of a disorder.
Rates for the most severe forms of mental disorders have been estimated to be between 2.6 and 2.8 percent of adults aged 18 years and older during any one year.13, [14] Despite the effectiveness of treatment and the many paths to obtaining a treatment of choice, only 25 percent of persons with a mental disorder obtain help for their illness in the health care system. In comparison, 60 to 80 percent of persons with heart disease seek and receive care.[15] More critically, 40 percent of all people who have a severe mental illness do not seek treatment from either general medical or specialty mental health providers. Indeed, the majority of persons with mental disorders do not receive mental health services. Of those aged 18 years and older getting help, about 15 percent receive help from mental health specialists.3 Of young people aged 9 to 17 years who have a mental disorder, 27 percent receive treatment in the health sector.[16] However, an additional 20 percent of children and adolescents with mental disorders use mental health services only in their schools.[17]
The direct costs of diagnosing and treating mental disorders totaled approximately $69 billion17 in 1996. Lost productivity and disability insurance payments due to illness or premature death accounted for an additional $74.9 billion.17 Crime, criminal justice costs, and property loss contributed another $6 billion to the total cost of mental illness. People with mental illnesses are overrepresented in jail populations; many do not receive treatment.[18] Of the $69 billion spent for diagnosing and treating mental disorders, nearly 70 percent was for the services of mental health specialty providers, with most of the remainder for general medical services providers. The majority—53 percent—of mental health treatment was paid for by public sector sources, including the States and local governments as well as Medicaid and Medicare and other Federal programs; 47 percent of expenditures were from private sources. Of expenditures from private sources, almost 60 percent were from private insurance.17 The remainder came from out-of-pocket payments, including insurance copayments, with a small amount from sources such as foundations.
Research on the brain and behavior in mental illness and mental health is moving at a rapid pace. An increasingly strong consumers’ movement in the mental health field is adding urgency to the tasks of translating new knowledge into clinical practices and refining service delivery systems to use new and emerging information optimally for patient/consumer needs. Consumer and family organizations, which formed out of concern over frequent fragmentation of mental health services and lack of accessibility to such services, have assumed a substantial role in supporting development of mental health services. Diverse groups share overlapping goals, including overcoming stigma and preventing discrimination toward persons with mental illness, promoting self-help groups, and promoting recovery from mental illness.18
The co-occurrence of addictive disorders among persons with mental disorders is gaining increasing attention from mental health professionals. Among adults aged 18 years and older with a lifetime history of any mental disorder, 29 percent have a history of an addictive disorder; of those with an alcohol disorder, 37 percent have had a mental disorder; and among those with other drug disorders, 53 percent have had a mental disorder.17 Having both mental and addictive disorders within the same year is a particularly significant clinical treatment issue, complicating treatment for each disorder. About 3 percent of the population aged 18 years and older has been identified as having co-occurring mental and addictive disorders in 1 year.3, 14 Of those with a serious mental illness, 15 percent have both types of disorder in 1 year, and of those with a severe and persistent mental illness, 27 percent have both mental and addictive disorders.14 Co-occurring, or comorbid, mental and addictive disorders are estimated to affect 50 to 60 percent of homeless persons.[19] Comorbid mental and addictive disorders also are evident in children and adolescents.[20] Especially at risk for alcohol use problems are boys diagnosed with so-called externalizing disorders such as conduct problems, oppositional-defiant disorder, and attention deficit/hyperactivity disorder (ADHD).[21] From public health promotion and disease prevention perspectives, it is noteworthy that children and adolescents with mental illnesses often do not become substance abusers until after the mental illness becomes apparent.[22] This time lag creates a window of opportunity when prevention of substance abuse in these children may be possible.20
As the life expectancy of individuals continues to grow longer, the sheer number—although not necessarily the proportion—of persons experiencing mental disorders of late life will expand. This trend will present society with unprecedented challenges in organizing, financing, and delivering effective preventive and treatment services for mental health in this population. As recognition continues to grow that depression and certain cognitive losses are treatable disorders and not inevitable concomitants of aging, diagnostic precision in later life and provision of targeted treatment are increasingly urgent.
Health care in the United States continues to undergo fundamental structural changes that require creative and flexible responses from service providers, administrators, researchers, and policymakers alike. Two prominent forces of change are Federal and State efforts to improve access to health care, including mental health care, and the rapid growth and impact of managed care. In 1998, the Mental Health Parity Act (P.L. 104-204) was implemented to help increase access to care. (The term “parity” or “mental health parity” refers generally to insurance coverage for mental health services that includes the same benefits and restrictions as coverage for other health services.) Although the Federal Mental Health Parity Act is quite limited in reducing insurance coverage discrepancies between physical and mental disorders, 53 percent of the U.S. population is now covered by State mental health parity laws.
Although mental illnesses, for the most part, are equal opportunity disorders, there are some marked differences in how they present themselves and how they are prevented, diagnosed, and treated by gender, racial and ethnic group, and age.17
Differences between men and women are evident in the number of cases of particular mental disorders. For example, major depression affects approximately twice as many women as men.[23] Women who are poor, have little formal schooling, and are on welfare or are unemployed are more likely to experience depression than women in the general population. Anxiety, panic, and phobic disorders affect two to three times as many women as men.[24], [25], [26]
Risk for engaging in suicidal behaviors also differs by gender. A history of physical or sexual abuse appears to be a serious risk factor for suicide attempts in both women and men.[27], [28] Women attempt suicide more often than men,[29] but men’s risk of completed suicide is on average four and one half times higher than women’s.[30] This suicide gender gap begins in adolescence and grows through middle and later life.[31]
Specific mental disorders affect men and women at particular stages of life. Schizophrenia occurs more often in young men than in women and usually has its onset in the late teen and early adult years. Eating disorders, affecting up to 2 percent of the population, arise predominantly—but not exclusively—in adolescent and young adult women (90 percent of all cases); the median age of onset is 17 years.2 Eating disorders often persist into adulthood and have among the highest death rates of any mental disorder.[32] Alzheimer’s disease affects equal numbers of women and men, although women’s longer average life spans mean that more women than men have Alzheimer’s disease at any point in time.[33]
Mental disorders, in aggregate, are as common later in life as they are at other ages, although rates for specific mental disorders vary depending on age and gender.[34] In any one-year period, the number of cases of major depression in people aged 65 years and older is approximately 1 percent, which is about half the rate among persons aged 45 to 64 years.[35] Depression rates are much higher, however, among older people who experience a physical health problem—12 percent for persons hospitalized for problems such as hip fractures or heart disease.[36] Depression rates for older persons in nursing homes range from 15 to 25 percent.[37] The number of cases of dementias, such as Alzheimer’s disease and other severe losses of mental abilities, are as high as 12 percent among persons aged 65 years and older.[38] By age 85 years, the rate grows to 25 percent.[39]
In contrast, rates of primary psychotic disorders drop with age;[40] thus, schizophrenia and persistent paranoid disorders affect fewer than 0.5 percent of older adults.[41] Although fewer old persons attempt suicide than do young persons,[42] the rate of completed suicide is highest among elderly men, who account for about 80 percent of suicides among persons aged 65 years and older.[43] Moreover, elderly white men have a suicide rate six times the national average.[44]
Caution is needed, however, when discussing differences among racial and ethnic groups in the rates of mental illness. Studies of the number of cases of mental health problems among racial and ethnic populations, while increasing in number, remain limited and often inconclusive. Discussion of the rates of existing cases must consider differences in how persons of different cultures and racial and ethnic groups perceive mental illness. Behavioral problems that Western medicine views as signs of mental illness may be assessed differently by individuals in various racial and ethnic groups. With this caution in mind, along with the recognition that sample sizes for racial and ethnic groups may be limited, examination of existing large-scale studies for mental health trends among racial and ethnic groups remains important.
Mental disorders are not only the cause of limitations of various life activities but also can be a secondary problem among people with other disabilities. Depression and anxiety, for example, are seen more frequently among people with disabilities than those without disabilities.[45]
Promising universal and targeted preventive interventions, implemented according to scientific recommendations, have great potential to reduce the risk for mental disorders and the burden of suffering in vulnerable populations. Also, social and behavioral research is beginning to explore the concept of resilience to identify strengths that may promote health and healing. It is generally assumed that resilience involves the interaction of biological, psychological, and environmental processes. With increased understanding of how to identify and promote resilience, it will be possible to design effective programs that draw on such internal capacity.
There is increasing awareness and concern in the public health sector regarding the impact of stress, its prevention and treatment, and the need for enhanced coping skills. Stress may be experienced by any person and provides a clear demonstration of mind-body interaction. Coping skills, acquired throughout the lifespan, are positive adaptations that affect the ability to manage stressful events. Additional research can help quantify the public health burden of stress and identify ways to prevent or alleviate it through environmental or individual strategies.
Progress in fundamental science and an emphasis on translating new knowledge into clinical applications can strengthen opportunities for future clinical and service system innovations. Research-based treatments afford an unprecedented opportunity to achieve a major reduction in the burden of disease associated with mental illness. With enhancements of clinical services and service systems, recovery is an achievable objective of mental health clinical interventions.
Evidence that mental disorders are legitimate and highly responsive to appropriate treatment promises to be a potent antidote to stigma. Stigma creates barriers to providing and receiving competent and effective mental health treatment and can lead to inappropriate treatment, unemployment, and homelessness. The elimination of stigma associated with mental disorders will in turn encourage more individuals to seek needed mental health care.
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Anxiety disorders: Anxiety disorders have multiple physical and psychological symptoms, but all have in common feelings of apprehension, tension, or uneasiness. Among the anxiety disorders are panic disorder, agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder.
Case management: Practice in which the service recipient is a partner in his or her recovery and self-management of mental illness and life.
Co-occurring/comorbidity: In general, the existence of two or more illnesses—whether physical or mental—at the same time in a single individual. In this chapter, comorbidity specifically means the existence of a mental illness and a substance abuse disorder or a mental and a physical illness in the same person at the same time.
Consumer: Any person using mental health services.
Cultural competence: In this chapter, a group of skills, attitudes, and knowledge that allows persons, organizations, and systems to work effectively with diverse racial, ethnic, and social groups.
Depression: A state of low mood that is described differently by people who experience it. Commonly described are feelings of sadness, despair, emptiness, or loss of interest or pleasure in nearly all things. Depression also can be experienced in other disorders such as bipolar disorder (manic-depressive disorder).
Diagnosable mental illness: Includes all people with a mental illness in a specified population group, whether or not they have received a formal diagnosis from a medical or mental health professional.
Homeless person: A person who lacks housing. The definition also includes a person living in transitional housing or a person who spends most nights in a supervised public or private facility providing temporary living quarters.
Juvenile justice facility: Includes detention centers, shelters, reception or diagnostic centers, training schools, ranches, forestry camps or farms, halfway houses and group homes, and residential treatment centers for young offenders.
Mental health services: Diagnostic, treatment, and preventive care that helps improve how persons with mental illness feel both physically and emotionally as well as how they interact with other persons. These services also help persons who have a strong risk of developing a mental illness.
Mental illness: The term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions characterized by alterations in thinking, mood, or behavior (or some combination thereof) that are all mediated by the brain and associated with distress or impaired functioning or both. Mental disorders spawn a host of human problems that may include personal distress, impaired functioning and disability, pain, or death. These disorders can occur in men and women of any age and in all racial and ethnic groups. They can be the result of family history, genetics, or other biological, environmental, social, or behavioral factors that occur alone or in combination.
Parity, mental health parity: Equivalent benefits and restrictions in insurance coverage for mental health services and for other health services.
Resilience: Manifested competence in the context of significant challenges to adaptation or development.
Schizophrenia: A mental disorder lasting for at least 6 months, including at least 1 month with two or more active-phase symptoms. Active-phase symptoms include delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Schizophrenia is accompanied by marked impairment in social or occupational functioning.
Screening for mental health problems: A brief formal or informal assessment to identify persons who have mental health problems or are likely to develop such problems. The screening process helps determine whether a person has a problem and, if so, the most appropriate mental health services for that person.
Serious emotional disturbance (SED): A diagnosable mental disorder found in persons from birth to age 18 years that is so severe and long lasting that it seriously interferes with functioning in family, school, community, or other major life activities.
Serious mental illness (SMI): A diagnosable mental disorder found in persons aged 18 years and older that is so long lasting and severe that it seriously interferes with a person’s ability to take part in major life activities.
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