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Part 1
Foundations
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Chapter 1
Introduction
This chapter introduces the concepts of mental health and mental illness. It provides an overview of the contexts within which mental illnesses are prevented, diagnosed, and treated and the many problems such conditions pose for patients and their families. The topics discussed in this chapter will be relevant throughout the entire book.
1.1 Mental Health and Mental Illness
Mental health refers to the successful performance of mental function, resulting in productive activities, fulfilling relationships, and the ability to adapt to change and cope with adversity. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem. People experiencing emotional well-being or mental health function comfortably in society and are satisfied with their achievements. Mental health is one of the leading health indicators that reflect the major public health concerns in the United States. Related indicators of interest to the mental health community include substance abuse, injury and violence, and access to healthcare.
The American Psychiatric Association (APA) defines mental illness as a clinically significant behavioral or psychological syndrome experienced by a person and marked by distress, disability, or the risk of suffering, disability, or loss of freedom. The symptoms of the disorder must be above and beyond expected reactions to an everyday event. The behavioral or psychological condition must result from brain functioning or malfunctioning, and it must cause the person distress, impairment, or both. It cannot be a cultural practice to which the majority culture in a society objects or that might cause distress to non-members of a cultural group. For example, some cultures believe that women should be subservient to men and expect the behavior of both sexes to reflect this idea. People of Western cultures might view such women as dependent or co-dependent, yet the behavior of these women is perfectly normal within the parameters of their own culture.
1.2 Incidence and Prevalence of Mental Illness
Psychiatric illnesses are common in the United States and internationally. The prominence of mental disorders in the total pattern of worldwide morbidity and mortality has been reported by the World Health Organization (WHO). According to their 2002 estimates, mental illnesses account for 25% of all disability across major industrialized countries. Mental illness ranks first in terms of causing disability in the US, Canada, and Western Europe.
In the US an estimated 26.2% of people (57.7 million) suffer from a diagnosable mental disorder in a given year. Data from the National Comorbidity Survey suggests that an estimated 13 million US adults (approximately 1 in 17) have a seriously debilitating mental illness. The main burden of illness is concentrated in this smaller population. Mental disorders are the leading cause of disability in the US and Canada for ages 15–44. Nearly half of people having any mental disorder meet the criteria for two or more disorders. In terms of mortality, suicide alone is the eleventh leading cause of death in the US, with approximately 30 000 deaths per year, and this is an issue of concern worldwide as well. Determining the costs associated with mental illness is challenging, but estimates suggest annual treatment costs in the US of $100 billion, with significantly more for indirect costs; $193 billion per year is estimated for lost earnings alone.
At least 20% of children in the United States have a diagnosable mental disorder; only 5% of these children have severely impaired functioning. In adults aged 18–54 years, 14.9% have anxiety disorders, 7.1% have mood disorders, and 1.3% have schizophrenia. Depression, a serious mental health problem in any age group, is particularly problematic in older adults. Between 8% and 15% of older adults have depression, but the condition is often undiagnosed and untreated in this age group because depression is mistakenly thought of as part of “normal aging.” People aged 65 years or older have the highest suicide rates of any age group. According to the Alzheimer's Association, Alzheimer's disease occurs in 8–15% of those older than 65 years (4.5 million cases) and that number is expected to increase to 11–16 million in the US by 2050. Approximately 125 000 people age 22–64 with mental illness live in nursing homes, 283 800 are incarcerated. Of 2 million individuals who are homeless over the course of a year, 50% have a mental illness and/or substance abuse disorder.
Table 1.1 contains National Institute of Mental Health statistics on the prevalence of some of the more common mental illnesses.
Table 1.1 Prevalence of mental illnesses in the United States.
Source: National Institute on Mental Health
| Mood disorders (major depressive disorder, dysthymic disorder and bipolar disorder) | Approximately 20.9 million US adults, or about 9.5% of the population aged 18 and older, have a mood disorder in a given year |
| Major depressive disorder | Major depressive disorder affects approximately 14.8 million US adults, or about 6.7% of the population aged 18 and older in a given year |
| Dysthymic disorder | Dysthymic disorder affects approximately 1.5% of the US population aged 18 and older in a given year (this translates to about 3.3 million US adults) |
| Bipolar disorder | Bipolar disorder affects approximately 5.7 million US adults, or about 2.6% of the population aged 18 and older in a given year |
| Suicide | In 2006, 33 300 (approximately 11 per 100 000) people died by suicide in the US |
| Schizophrenia | Approximately 2.4 million US adults, or about 1.1% of the population aged 18 and older, have schizophrenia in a given year |
| Anxiety disorders | Approximately 40 million US adults aged 18 and older, or about 18.1% of people in this age group, have an anxiety disorder in a given year |
| Panic disorder | Approximately 6 million US adults aged 18 and older, or about 2.7% of people in this age group, have panic disorder in a given year |
| Obsessive–compulsive disorder (OCD) | Approximately 2.2 million US adults aged 18 and older, or about 1.0% of people in this age group, have OCD in a given year |
| Post-traumatic stress disorder (PTSD) | Approximately 7.7 million US adults aged 18 and older, or about 3.5% of people in this age group, have PTSD in a given year |
| Generalized anxiety disorder (GAD) | Approximately 6.8 million US adults, or about 3.1% of people aged 18 and over, have GAD in a given year |
| Social phobia | Approximately 15 million US adults aged 18 and over, or about 6.8% of people in this age group, have social phobia in a given year |
1.3 Etiology of Mental Illness
The specific causes of mental illnesses are largely unknown. The pathways leading to mental disorders involve an enormously complex set of interactions. Multiple factors involving genetic predispositions and environmental influences contribute to the development of mental disorders. Mental Health: A Report of the Surgeon General identifies the roots of mental illness as some combination of biologic and environmental factors; however, the document cautions against thinking that any one gene is responsible for any mental disorder. In all likelihood small variations in many genes disrupt healthy brain functioning, and under certain environmental conditions this disruption can result in mental illness.
1.4 The Burden of Mental Illness
Given the significant numbers of people with a mental illness, nearly two-thirds of affected individuals fail to seek treatment. Several factors contribute to this reality; they are part of the world within which people with mental illnesses and their families contend.
1.4.1 Stigma
Mental illnesses are exceedingly stigmatized, evoking fear and prejudice based on misunderstanding and misconceptions of these conditions. This stigma is not limited to the public itself but to professionals as well. Misconceptions have ranged from attributing mental illnesses to demonic possession to blaming victims for their problems. This stigmatization has led to discrimination and intolerance based on ignorance of mental illness itself. Stereotyping has had profound consequences for individuals with mental illnesses and their families. It has discouraged public sympathy for the traumatic life dislocation of people with brain disorders, and has prevented public policy from allocating resources (such as medication parity) that would meet their needs. For example, many health plans cover the costs of psychotropic medications at far lower rates than they do for other medications.
Of great concern is the role that stigma plays with children in that it can lead parents to avoid seeking treatment that could dramatically improve their children's condition. Children with psychiatric disorders are stigmatized as much as their adult counterparts by both other children and adults. In a large study of US parents, 30% said they would not want their child to become friends with a child who had depression, and 25% said the same about a child with attention-deficit hyperactivity disorder. Almost 20% of the sample said they would not want a child with either disorder to live next door. Responses to the same questions substituting a “physical” illness were much more generous and understanding. Similar levels of stigmatization have been found repeatedly across other studies with others, such as adolescents, adults, and geriatric populations.
In the policy arena, research funding for the treatment of mental illnesses is often far lower than funds allocated for funding of other disease states. At an individual level, people with mental illness must deal with a painful level of rejection, isolation, and discrimination that erodes their self-assurance and can systematically undermine their self-confidence. People with mental illness are often discounted and invalidated. In the late 1990s when patients and families reported to state officials that they were being mistreated in private mental hospitals, they were dismissed by their third-party payers and regulators until investigative journalists exposed very real instances of systematic abuse. The very label of a mental illness can lead patient behavior to be needlessly pathologized. Stigma builds or reinforces interpersonal, financial, employment, and social barriers to accessing care.
1.4.2 The Context of Treatment
The President's New Freedom Commission on Mental Health was charged with studying the mental-health care delivery system, identifying the problems and gaps, and recommending changes that would facilitate better outcomes for adults and children with serious mental and emotional conditions. Spanning 12 months of document review, interview with patients, families, providers, and experts, the Commission declared that the mental health delivery system in the US is fragmented and in disarray and that fragmentation too often lead to unnecessary and costly disability, homelessness, school failure and incarceration. Particularly devastating was its conclusion that the US mental health system was not oriented to the most important goal of the people it serves: the hope of recovery.
The fragmented mental-health care delivery system in the US often provides inadequate, inappropriate, or no care. It is very difficult for clients and their families to determine what services are needed and where to find them. The majority of inpatient mental health settings provide services based on a traditional model of care that is often uninformed by recovery-oriented principles or research. This traditional approach is often characterized by paternalistic attitudes, staff-to-patient power differentials, homogenized treatment practices, a lack of voice from the individuals being served, outdated programming, and blatant discrimination as to language practices and policies in inpatient settings.
Common practices include talking about people as if they are their disease (“schizophrenics”), documentation in the medical record that is pejorative (“needy,” “attention-seeking” or “manipulative”), arbitrary wake-up and bedtime rules, and expectations that patients and their families will passively accept treatment team recommendations that they may not have been involved with developing. These conventions can be experienced as patronizing, shaming, and disrespectful, and they can contribute to lack of trust, lack of treatment adherence, and poor outcomes.
Poor outcomes also result from the lack of resources for effective care. While the effectiveness of psychotropic medications has reduced the need for hospitalization when hospitalization is necessary, lengths of stay in hospitals have decreased. Managed care companies often mandate certain types of treatment, favoring short-term time-limited approaches, even when a person's needs are for longer, more intensive treatment. For these and...
