# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 18 {#section-1 .Chapter-#}

# Mental Health and Mental Disorders

Co-Lead Agencies: National Institutes of Health\
Substance Abuse and Mental Health Services\
Administration

### Contents {#contents .Heading-Special}

[Goal Page 18-3](#goal)

[Overview Page 18-3](#overview)

[Issues Page 18-3](#issues)

[Trends Page 18-6](#trends)

[Disparities Page 18-7](#disparities)

[Opportunities Page 18-9](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
18-10](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010Summary of Objectives Page
18-11](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
18-12](#healthy-people-2010-objectives)

[Mental Health Status Improvement Page
18-12](#mental-health-status-improvement)

[Treatment Expansion Page 18-16](#treatment-expansion)

[State Activities Page 18-21](#state-activities-1)

[Related Objectives From Other Focus Areas Page
18-22](#related-objectives-from-other-focus-areas)

[Terminology Page 18-25](#terminology)

[References Page 18-27](#references)

## Goal

Improve mental health and ensure access to appropriate, quality mental
health services.

## Overview

*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.

### Issues

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.
![](media/image2.wmf){width="4.591666666666667in"
height="4.781944444444444in"}

-   *Schizophrenia* will affect more than 2 million people in the United
    States in 1 year.Error: Reference source not found 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.

-   *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.Error: Reference source not found 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]

-   *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.Error: Reference source not found**^,^** [^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.Error: Reference source not found 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 billionError: Reference source not found in 1996.
Lost productivity and disability insurance payments due to illness or
premature death accounted for an additional \$74.9 billion.Error:
Reference source not found 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.Error: Reference source not found
The remainder came from out-of-pocket payments, including insurance
copayments, with a small amount from sources such as foundations.

### Trends![](media/image3.wmf){width="4.501388888888889in" height="3.94375in"}

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.Error: Reference
source not found

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.Error: Reference source not found
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.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** 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.Error: Reference source
not found 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.Error: Reference source not found

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.

### Disparities

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.Error: Reference source not found

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.Error: Reference source not found 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]

### Opportunities

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.

## Interim Progress Toward Year 2000 Objectives

Four Healthy People 2000 objectives focus on individual behavior in
coping with the symptoms of mental disorders: controlling stress,
seeking help with personal and emotional problems, obtaining treatment
for depression, and using community support programs for severe and
persistent disorders. The least progress was achieved on objectives
indicative of chronic stress exposure; that is, controlling stress and
seeking treatment for depression showed the least progress. Objectives
that involve seeking help for personal and emotional problems that
result from disabilities, particularly those associated with severe and
persistent mental disorders, showed the most progress. Five Healthy
People 2000 objectives focus on the development of service delivery
mechanisms for early recognition of symptoms and interventions, as well
as reductions in the negative consequences of mental disorders. A slight
decline in the proportion of nurse practitioners who typically inquire
about the parent-child relationship has been documented (from 55 percent
to 51 percent). In addition, large declines have taken place in nurse
practitioners who typically inquire about their adult patients'
cognitive, emotional, or behavioral functioning (from 35 percent to 19
percent for cognitive functioning and from 40 percent to 26 percent for
emotional or behavioral functioning). Some offsetting increases in
treatment and referral activity are reported (from 20 percent to 22
percent for cognitive problems, from 23 percent to 33 percent for
emotional/behavioral problems).

Six Healthy People 2000 objectives focus on the distress and dysfunction
that accompany the cognitive, emotional, and behavioral symptoms of
mental disorders. The age-adjusted suicide rate in the total population
has slightly declined and by 1997 already had met the target level; the
rate for white men aged 65 years and older, who began the decade at
highest risk for suicide (44.4 per 100,000), had declined below the year
2000 target in 1994 (38.9 per 100,000) and had declined further by 1997
(35.5 per 100,000).

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review 1998--99.*

## Healthy People 2010Summary of Objectives

### Mental Health and Mental Disorders {#mental-health-and-mental-disorders-1 .Heading-Special-Sub}

**Goal:** Improve mental health and ensure access to appropriate,\
quality mental health services.

+--------+-------------------------------------------------------------+
| **Nu   | **Objective Short Title**                                   |
| mber** |                                                             |
+--------+-------------------------------------------------------------+
| **     |                                                             |
| Mental |                                                             |
| Health |                                                             |
| Status |                                                             |
| I      |                                                             |
| mprove |                                                             |
| ment** |                                                             |
+--------+-------------------------------------------------------------+
| 18-1   | Suicide                                                     |
+--------+-------------------------------------------------------------+
| 18-2   | Adolescent suicide attempts                                 |
+--------+-------------------------------------------------------------+
| 18-3   | Serious mental illness (SMI) among homeless adults          |
+--------+-------------------------------------------------------------+
| 18-4   | Employment of persons with SMI                              |
+--------+-------------------------------------------------------------+
| 18-5   | Eating disorder relapses                                    |
+--------+-------------------------------------------------------------+
| **Tre  |                                                             |
| atment |                                                             |
| Expan  |                                                             |
| sion** |                                                             |
+--------+-------------------------------------------------------------+
| 18-6   | Primary care screening and assessment                       |
+--------+-------------------------------------------------------------+
| 18-7   | Treatment for children with mental health problems          |
+--------+-------------------------------------------------------------+
| 18-8   | Juvenile justice facility screening                         |
+--------+-------------------------------------------------------------+
| 18-9   | Treatment for adults with mental disorders                  |
+--------+-------------------------------------------------------------+
| 18-10  | Treatment for co-occurring disorders                        |
+--------+-------------------------------------------------------------+
| 18-11  | Adult jail diversion programs                               |
+--------+-------------------------------------------------------------+
| #      |                                                             |
| ###### |                                                             |
| # Stat |                                                             |
| e Acti |                                                             |
| vities |                                                             |
+--------+-------------------------------------------------------------+
| 18-12  | State tracking of consumer satisfaction                     |
+--------+-------------------------------------------------------------+
| 18-13  | State plans addressing cultural competence                  |
+--------+-------------------------------------------------------------+
| 18-14  | State plans addressing elderly persons                      |
+--------+-------------------------------------------------------------+

## Healthy People 2010 Objectives

### Mental Health Status Improvement

18-1. Reduce the suicide rate.

**Target**: 5.0 suicides per 100,000 population.

**Baseline:** 11.3 suicides per 100,000 population occurred in 1998 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1998**                     | **Suicides**        |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 11.3                |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 12.6                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 6.6                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 5.8                 |
+------------------------------------------------+---------------------+
| > White                                        | 12.2                |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 6.3                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 11.8                |
+------------------------------------------------+---------------------+
| > Black or African American                    | 6.0                 |
+------------------------------------------------+---------------------+
| > White                                        | 12.8                |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 4.3                 |
+------------------------------------------------+---------------------+
| > Male                                         | 19.2                |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 to 64 years)      |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 17.9                |
+------------------------------------------------+---------------------+
| > High school graduate                         | 19.2                |
+------------------------------------------------+---------------------+
| > At least some college                        | 10.0                |
+------------------------------------------------+---------------------+
| ###### Age (not age adjusted)                  |                     |
+------------------------------------------------+---------------------+
| > 10 to 14 years                               | 1.6                 |
+------------------------------------------------+---------------------+
| > 15 to 19 years                               | 8.9                 |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | 13.6                |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

18-2. Reduce the rate of suicide attempts by adolescents.

**Target:** 12-month average of 1 percent.

**Baseline:** 12-month average of 2.6 percent of adolescents in grades 9
through 12 attempted suicide in 1999.

**Target setting method:** Better than the best.

**Data source:** Youth Risk Behavior Surveillance System (YRBSS), CDC,
NCCDPHP.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Students in Grades 9 Through 12, 1999**      | **Suicide           |
|                                                | Attempts**          |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 2.6                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 3.1                 |
+------------------------------------------------+---------------------+
| > White                                        | 2.2                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 3.0                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 2.6                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 2.9                 |
+------------------------------------------------+---------------------+
| > White                                        | 1.9                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 3.1                 |
+------------------------------------------------+---------------------+
| > Male                                         | 2.1                 |
+------------------------------------------------+---------------------+
| **Parents' education level**                   |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DNC                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | DNC                 |
+------------------------------------------------+---------------------+
| > At least some college                        | DNC                 |
+------------------------------------------------+---------------------+
| ###### Sexual orientation                      | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Suicide is a complex behavior that can be prevented in many cases by
early recognition and treatment of mental disorders. It was the ninth
leading cause of death in the United States in 1996 and the third
leading killer of young persons between age 15 and 24 years.[^46]**^,^**
[^47]**^,^** [^48]**^,^** [^49] At least 90 percent of all people who
kill themselves have a mental or substance abuse disorder, or a
combination of disorders. However, most persons with a mental or
substance abuse disorder do not kill themselves; thus other factors
contribute to suicide risk. In addition to mental and substance abuse
disorders, risk factors include prior suicide attempt, stressful life
events, and access to lethal suicide methods. Suicide is difficult to
predict; therefore, preventive interventions focus on risk factors.
Thus, reduction in access to lethal methods and recognition and
treatment of mental and substance abuse disorders are among the most
promising approaches to suicide prevention. More targeted approaches
should consider risk factors most salient and appropriate for select
populations.

18-3. Reduce the proportion of homeless adults who have\
serious mental illness (SMI).

**Target:** 19 percent.

**Baseline:** 25 percent of homeless adults aged 18 years and older had
SMI in 1996.

**Target setting method:** 24 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** Projects for Assistance in Transition from Homelessness
(PATH) Annual Application, SAMHSA, CMHS.

> **Data for population groups currently are not collected.**

Approximately one-quarter of homeless persons in the United States have
a serious mental illness (SMI).[^50] New approaches developed over the
past 10 years provide ways to lower the number of persons who are
homeless and who also have SMI. Using persistent patient outreach and
engagement strategies, service providers are helping homeless persons
with SMI connect with mainstream treatment\
systems.[^51]**^,^** [^52]

Treatment alone, however, is not enough. Once permanent housing is
located, appropriate mental health and social supports can help persons
with mental illness remain off the street. Much of this support occurs
in the form of case management, particularly if it is responsive both to
emerging mental health issues and to the skills a person needs to
function and thrive in the community.

18-4. Increase the proportion of persons with serious mental\
illness (SMI) who are employed.

**Target:** 51 percent.

**Baseline:** 43 percent of persons aged 18 years and older with SMI
were\
employed in 1994.

**Target setting method:** 19 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

> **Data for population groups currently are not analyzed.**

Rehabilitation is an essential part of care for adults with serious
mental illness. To promote independent living, rehabilitation programs
often evaluate and place these persons in jobs. Rehabilitation programs
also provide continuing support and help ensure that the placement is
working well. Research shows that working provides both economic and
personal benefits for persons with SMI that extend beyond a paycheck and
workplace companionship.[^53] Employment also improves self-esteem and
independence; it helps a person to manage his or her own illness and
return to community life.[^54]**^,^** [^55] A majority of persons with
SMI want to be employed and rank employment as a primary personal
goal.[^56] Helping persons with mental illness secure employment can
reduce the use of mental health services and reduce the number of
persons who receive Federal and State disability payments.Error:
Reference source not found

18-5. (Developmental) Reduce the relapse rates for persons\
with eating disorders including anorexia nervosa and\
bulimia nervosa.

**Potential data source:** Prospective studies of patients with anorexia
or bulimia nervosa, NIH, NIMH.

Anorexia nervosa is the most severe eating disorder, characterized by
extreme and often life-threatening[^57] weight loss associated with a
distorted body image and a pathological fear of gaining weight. In cases
of severe weight loss, hospital treatment often is needed. Studies
suggest that from 30 to 50 percent of patients treated successfully in
the hospital become ill again within 1 year of leaving the
hospital.[^58]**^,^** [^59] Efforts are under way to develop and test
specific interventions that can prevent relapse in these patients. For
instance, a particular kind of psychotherapy---called
cognitive-behavioral treatment---has been found to lower relapse rates
in persons with anorexia nervosa.[^60] Treatments using medications also
have been tried, both alone and in combination with talking therapy.
Preliminary reports suggest that it might be possible to decrease the
chance of relapse, resulting in better long-term prospects for persons
with severe anorexia nervosa.

Bulimia nervosa is an eating disorder that involves eating a lot of food
(binge eating) and then eliminating it (purging), whether through
self-induced vomiting or through the use of diuretics or other
medications. Effective short-term treatments exist for this serious
mental health problem. When "remission" is defined as being symptom-free
of binge eating and purging for at least 4 weeks, about 25 percent of
those in remission had a relapse in less than 3 months. Around 9 months
after remission, fewer than half (49 percent) of the persons remained
symptom-free.[^61] Risk for relapse seems to drop after 4 years of being
symptom-free.[^62]

### Treatment Expansion

18-6. (Developmental) Increase the number of persons seen\
in primary health care who receive mental health screening and
assessment.

**Potential data source:** Primary Care Data System/Federally Qualified
Health Centers, HRSA.

The general medical and primary care sector consists of health care
professionals such as internists, pediatricians, and nurse practitioners
in office-based practice, clinics, acute medical and surgical hospitals,
and nursing homes. Close to 6 percent of the adult U.S. population use
the general medical sector for mental health care, with an average of
about 4 mental health visits per year---far lower than the average of 14
visits per year found in the specialty medical sector.Error: Reference
source not found**^,\ Error:\ Reference\ source\ not\ found^** The
general medical sector has long been identified as the initial point of
contact for many adults with mental disorders; for some, these providers
may be their only source of mental health services. This attention to
mental state in primary care can promote early detection and
intervention for mental health problems.

18-7. (Developmental) Increase the proportion of children\
with mental health problems who receive treatment.

**Potential data source:** National Household Survey on Drug Abuse
(NHSDA), SAMHSA, OAS.

For many children aged 18 years and under, lifelong mental disorders may
start in childhood or adolescence. For many other children, normal
development is disrupted by biological, environmental, and psychosocial
factors, which impair their mental health, interfere with education and
social interactions, and keep them from realizing their full potential
as adults.

Expanding effective services for children, particularly for those with
serious emotional disturbance, depends on promoting effective
collaboration across critical areas of support: families, social
services, health, mental health, juvenile justice, and schools. Better
services and collaboration for children with serious emotional
disturbance and their families will result in greater school retention,
decreased contact with the juvenile justice system, increased stability
of living arrangements, and improved educational, emotional, and
behavioral development.[^63]**^,^** [^64]

18-8. (Developmental) Increase the proportion of juvenile justice
facilities that screen new admissions for mental health problems.

**Potential data source:** Inventory of Mental Health Services in
Juvenile Justice Facilities, SAMHSA.

It is estimated that over 100,000 youth are placed in juvenile justice
facilities annually.[^65] Although exact numbers of youths with mental
disorders among those entering this system are not available, the
proportion is considerably higher than in the general population. Not
surprisingly, problems of suicide, self-injurious behavior, and other
disorders are significant among youths in the juvenile justice
system.[^66] Screening activities, including parent or caregiver
interviews, should be conducted by qualified mental health
personnel.Error: Reference source not found This approach can help
ensure that all youths entering the juvenile justice system who also
have a treatable mental health problem are identified and receive
appropriate treatment.

18-9. Increase the proportion of adults with mental disorders who
receive treatment.

Target and baseline:

+------------+------------------------------+------------+------------+
| Objective  | Increase in Adults With      | 1997       | 2010\      |
|            | Mental\                      | Baseline\  | Target     |
|            | Disorders Receiving          | (unless    |            |
|            | Treatment                    | noted)     |            |
+------------+------------------------------+------------+------------+
|            |                              | #####      |            |
|            |                              | ## Percent |            |
+------------+------------------------------+------------+------------+
| **18-9a.** | Adults aged 18 to 54 years   | 47 (1991)  | 55         |
|            | with\                        |            |            |
|            | serious mental illness       |            |            |
+------------+------------------------------+------------+------------+
| **18-9b.** | Adults aged 18 years and     | 23         | 50         |
|            | older with recognized        |            |            |
|            | depression                   |            |            |
+------------+------------------------------+------------+------------+
| **18-9c.** | Adults aged 18 years and     | 60 (1984)  | 75         |
|            | older with schizophrenia     |            |            |
+------------+------------------------------+------------+------------+
| **18-9d.** | Adults aged 18 years and     | 38         | 50         |
|            | older with generalized       |            |            |
|            | anxiety disorder             |            |            |
+------------+------------------------------+------------+------------+

**Target setting method:** 17 percent improvement for 18-9a. (Better
than the best will be used when data are available.) Better than the
best for 18-9b, 18-9c, and 18-9d.

**Data sources**: Epidemiologic Catchment Area (ECA) Program, NIH,
NIMH;\
National Household Survey on Drug Abuse (NHSDA), SAMHSA, OAS; National
Comorbidity Survey, SAMHSA, CMHS; NIH, NIMH.

+----------------------------+-----------+---------+--------+--------+
| **Adults Aged 18 Years and | *         |         |        |        |
| Older With Mental          | *Received |         |        |        |
| Disorders, 1997 (unless    | Tr        |         |        |        |
| noted)**                   | eatment** |         |        |        |
+----------------------------+-----------+---------+--------+--------+
|                            | **18-9a.\ | **      | **1    | **1    |
|                            | Serious\  | 18-9b.\ | 8-9c.\ | 8-9d.\ |
|                            | Mental\   | Rec     | S      | Gener  |
|                            | Illness   | ognized | chizop | alized |
|                            | (aged 18  | Depre   | hrenia | A      |
|                            | to 54     | ssion** | (1     | nxiety |
|                            | years)    |         | 984)** | Diso   |
|                            | (1991)**  |         |        | rder** |
+----------------------------+-----------+---------+--------+--------+
|                            | Percent   |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > **TOTAL**                | 47        | 23      | 60     | 38     |
+----------------------------+-----------+---------+--------+--------+
| **Race and ethnicity**     |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > American Indian or       | DNA       | DSU     | DSU    | DSU    |
| > Alaska\                  |           |         |        |        |
| > Native                   |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Asian or Pacific         | DNA       | DSU     | DSU    | DSU    |
| > Islander                 |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Asian                    | DNA       | DNC     | DSU    | DNC    |
+----------------------------+-----------+---------+--------+--------+
| > Native Hawaiian and      | DNA       | DNC     | DSU    | DNC    |
| > other Pacific Islander   |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Black or African         | DNA       | 16      | DNC    | 26     |
| > American                 |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > White                    | DNA       | 24      | DNC    | 39     |
+----------------------------+-----------+---------+--------+--------+
|                            |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Hispanic or Latino       | DNA       | 20      | 42     | DSU    |
+----------------------------+-----------+---------+--------+--------+
| > Not Hispanic or Latino   | DNA       | DNC     | DNC    | 40     |
+----------------------------+-----------+---------+--------+--------+
| > Black or African         | DNA       | DNA     | 41     | DNA    |
| > American                 |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > White                    | DNA       | DNA     | 63     | DNA    |
+----------------------------+-----------+---------+--------+--------+
| **Gender**                 |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Female                   | DNA       | 24      | 63     | 32     |
+----------------------------+-----------+---------+--------+--------+
| > Male                     | DNA       | 21      | 51     | 49     |
+----------------------------+-----------+---------+--------+--------+
| **Education level**        |           |         |        |        |
+----------------------------+-----------+---------+--------+--------+
| > Less than high school    | DNA       | 22      | 48     | 48     |
+----------------------------+-----------+---------+--------+--------+
| > High school graduate     | DNA       | 19      | 71     | 34     |
+----------------------------+-----------+---------+--------+--------+
| > At least some college    | DNA       | 28      | 66     | 32     |
+----------------------------+-----------+---------+--------+--------+
| ###### Sexual orientation  | DNC       | DNC     | DNC    | DNC    |
+----------------------------+-----------+---------+--------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

**Serious mental illness.** Untreated mental illnesses have human and
economic costs associated with them[^67]**^,^** [^68] Lost productivity
due to illness, premature death, criminal justice interaction process,
and property loss are all part of these costs. Ninety percent of those
who complete suicide have a diagnosed mental illness.Error: Reference
source not found Helping persons with mental illnesses access
appropriate scientifically based treatments is essential.

**Depression.** At some time or another, virtually all adults will
experience a tragic or unexpected loss or a serious setback and times of
profound sadness, grief, or distress. Major depressive disorder,
however, differs both quantitatively and qualitatively from normal
sadness or grief, which is typically less pervasive and generally more
time-limited. Moreover, some of the symptoms of severe depression, such
as anhedonia (the inability to experience pleasure), hopelessness, and
loss of mood reactivity (the ability to feel a mood uplift in response
to something positive) only rarely accompany normal sadness. Suicidal
thoughts and psychotic symptoms such as delusions or hallucinations
virtually always signify a pathological state.[^69] Depression disrupts
the lives of depressed persons and their families and reduces economic
productivity. Depression also can result in suicide and has an
especially severe impact on women.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Treatment can
alleviate each of these problems. Available medications and
psychological treatments, alone or in combination, can help 80 percent
of those with depression.[^70]

Depression also has a deleterious impact on the economy, costing the
United States over \$40 billion each year, both in diminished
productivity and in use of health care resources. In the workplace,
depression is a leading cause of absenteeism and diminished
productivity.[^71] Although only a minority seek professional help to
relieve a mood disorder, depressed people are significantly more likely
than others to visit a physician for some other reason.[^72]

**Schizophrenia** is characterized by profound disruption in cognition
and emotion, affecting the most fundamental human attributes: language,
thought, perception, affect, and sense of self. Symptoms frequently
include hearing internal voices or experiencing other sensations not
connected to an obvious source (hallucinations) and assigning unusual
significance or meaning to normal events or holding fixed false beliefs.
No single symptom is definitive for diagnosis; rather, the diagnosis
encompasses a pattern of signs and symptoms, in conjunction with
impaired occupational or social functioning. The disorder affects 0.5 to
1 percent of the population over the course of a lifetime. Onset
generally occurs during young adulthood (mid-20s for men, late-20s for
women), although earlier and later onset do occur.[^73]

**Anxiety disorders**, which include generalized anxiety disorder, are
not only common in the United States, but they are ubiquitous across
human cultures.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^74] Twenty-four
percent of the population will experience an anxiety disorder, many with
overlapping substance abuse disorders.Error: Reference source not
found**^,^** [^75]**^,^** [^76] The longitudinal course of anxiety
disorders is characterized by relatively early ages of onset,
chronicity, relapsing or recurrent episodes of illness, and periods of
disability.[^77]**^,^** [^78]**^,^** [^79]**^,^** [^80] Panic disorder
and agoraphobia are associated with increased risks of attempted and
completed suicide.Error: Reference source not found**^,^** [^81]

18-10. (Developmental) Increase the proportion of persons with
co-occurring substance abuse and mental disorders who receive treatment
for both disorders.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; National Household Survey on Drug Abuse (NHSDA), SAMHSA,
OAS;\
Replication of National Comorbidity Survey, NIH, NIMH.

Co-occurring mental and addictive disorders are more common than
previously recognized. In general, 19 percent of the adult U.S.
population have a mental disorder alone (in 1 year); 3 percent have both
mental and addictive disorders; and 6 percent have addictive disorders
alone. Consequently, about 28 to 30 percent of the population have
either a mental or addictive disorder.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** The lifetime rates
of co-occurrence of mental disorders and addictive disorders are
strikingly high. About one in five persons in the United States
experience a mental disorder in the course of a year. Nearly one in
three adults who have a mental disorder in their lifetime also
experiences a co-occurring substance abuse (alcohol or other drugs)
disorder, which complicates treatment. Individuals with co-occurring
disorders are more likely to experience a chronic course and to use
services than are those with either type of disorder alone. Clinicians,
program developers, and policymakers need to be aware of these high
rates of comorbidity. While an integrated approach may be indicated for
persons with SMI and co-occurring addictive disorders, how public health
service systems can best address issues of treating the full range of
persons with co-occurring mental and substance-related disorders remains
a challenge. Treatment protocols continue to be refined as research
findings and promising practices are disseminated to programs and
practitioners.

18-11. (Developmental) Increase the proportion of local\
governments with community-based jail diversion\
programs for adults with serious mental illness (SMI).

**Potential data source:** National Survey of Jail Mental Health
Diversion\
Programs, SAMHSA.

Nearly 700,000 persons with active symptoms of serious mental illness
are admitted to jails each year. They constitute about 7 percent of the
jail population.[^82] Individuals with SMI were overrepresented in jails
compared to their numbers in the general population. Some people
arrested for nonviolent crimes could be better served if diverted from
the jail system to a community-based mental health treatment
program.[^83] Key components of a model diversion program are: (1)
identifying specific program elements for diversion with accompanying
resources and identified staff, (2) a specific target population, (3) a
goal of avoiding or decreasing the time of incarceration, and (4) a way
to link target population members with community-based mental health
services.Error: Reference source not found

### State Activities

18-12. Increase the number of States and the District of Columbia that
track consumers' satisfaction with the mental health services they
receive.

**Target:** 50 States and the District of Columbia.

**Baseline:** 36 States tracked consumers' satisfaction with the mental
health\
services they received in 1999.

**Target setting method:** Total coverage.

**Data source:** Mental Health Statistics Improvement Program, SAMHSA.

The health care industry increasingly is using consumer opinion to gain
information on service needs and changes. Patient satisfaction studies
are becoming standard practice for many health care organizations.
Health care executives have indicated that consumers have a major impact
on the development of health care products.[^84] Nearly 90 percent of
health care executives reported that they have expanded both the number
and type of services based on consumer preference. The Mental Health
Statistics Improvement Program has pioneered the development of a
consumer-oriented mental health report card that includes a consumer
survey designed to address questions of access, appropriateness,
quality, and outcome of care.

18-13. (Developmental) Increase the number of States, Territories, and
the District of Columbia with an operational mental health plan that
addresses cultural competence.

**Potential data source:** National Technical Assistance Center for
State Mental Health Systems, National Association of State Mental Health
Program Directors, National Research Institute; SAMHSA, CMHS.

To work effectively, health care providers need to understand the
differences in how various populations in the United States perceive
mental health and mental illness and treatment services. These factors
affect whether people seek mental health care, how they describe their
symptoms, the duration of care, and the outcomes of the care received.
Research has shown that various select populations use mental health
services differently. They may not seek mental health services in the
formal system, drop out of care, or seek care at much later stages of
illness, driving the service cost higher.[^85]**^,^** [^86]**^,^** [^87]
This pattern of use appears to be the result of a community-based mental
health service system that is not culturally relevant, responsive, or
accessible to select populations.Error: Reference source not
found**^,^** [^88]**^,^** [^89]**^,^** [^90] Hospitals have become the
primary mental health treatment site for a disproportionate number of
African Americans.[^91]**^,^** [^92]**^,^** [^93]**^,^** [^94]

18-14. Increase the number of States, Territories, and the District of
Columbia with an operational mental health plan that addresses mental
health crisis interventions, ongoing screening, and treatment services
for elderly persons.

**Target:** 50 States and the District of Columbia.

**Baseline:** 24 States had an operational mental health plan that
addressed mental health crisis interventions, ongoing screening, and
treatment services for elderly persons in 1997.

**Target setting method:** Total coverage.

**Data source:** National Technical Assistance Center for State Mental
Health\
Systems, National Association of State Mental Health Program Directors,\
National Research Institute; SAMHSA, CMHS.

The Nation is growing older; the number and proportion of the population
aged 65 years and older will grow rapidly after 2010. As the Nation
ages, the mental health needs of elderly persons must be addressed
because their needs will continue to grow. Mood disorders affect between
2 and 4 percent of community-living elderly persons.Error: Reference
source not found Elderly persons with clinically significant depressive
symptoms range from 10 to 15 percent of the U.S. population.[^95] State
mental health authorities and localities should become increasingly
engaged in meeting the mental health needs of this growing population.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-1. Persons with health insurance

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

1-4. Source of ongoing care

1-5. Usual primary care provider

1-6. Difficulties or delays in obtaining needed health care

1-7. Core competencies in health provider training

1-8. Racial and ethnic representation in health professions

1-10. Delay or difficulty in getting emergency care

1-11. Rapid prehospital emergency care

1-12. Single toll-free number for poison control centers

1-13. Trauma care systems

1-14. Special needs of children

1-15. Long-term care services

2\. Arthritis, Osteoporosis, and Chronic Back Conditions

2-4. Help in coping

3\. Cancer

3-10. Provider counseling about cancer prevention

6\. Disability and Secondary Conditions

6-1. Standard definition of people with disabilities in data sets

6-2. Feelings and depression among children with disabilities

6-3. Feelings and depression interfering with activities among adults\
with disabilities

6-4. Social participation among adults with disabilities

6-5. Sufficient emotional support among adults with disabilities

6-6. Satisfaction with life among adults with disabilities

6-7. Congregate care of children and adults with disabilities

6-8. Employment parity

6-9. Inclusion of children and youth with disabilities in regular
education\
programs

6-10. Accessibility of health and wellness programs

6-11. Assistive devices and technology

6-12. Environmental barriers affecting participation in activities

6-13. Surveillance and health promotion programs

7\. Educational and Community-Based Programs

7-1. High school completion

7-2. School health education

7-3. Health-risk behavior information for college and university
students

7-4. School nurse-to-student ratio

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-7. Patient and family education

7-9. Health care organization sponsorship of community health\
promotion activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

9\. Family Planning

9-1. Intended pregnancy

9-2. Birth spacing

9-3. Contraceptive use

9-4. Contraceptive failure

9-5. Emergency contraception

9-6. Male involvement in pregnancy prevention

9-7. Adolescent pregnancy

9-8. Abstinence before age 15 years

9-9. Abstinence among adolescents aged 15 to 17 years

9-10. Pregnancy prevention and sexually transmitted disease (STD)
protection

9-11. Pregnancy prevention education

9-13. Insurance coverage for contraceptive supplies and services

11\. Health Communication

11-1. Households with Internet access

11-2. Health literacy

11-3. Research and evaluation of communication programs

11-4. Quality of Internet health information sources

11-5. Centers for excellence

11-6. Satisfaction with health care providers' communication skills

13\. HIV

13-1. New AIDS cases

13-5. New HIV cases

13-13. Treatment according to guidelines

13-17. Perinatally acquired HIV infection

15\. Injury and Violence Prevention

15-10. Emergency department surveillance systems

15-11. Hospital discharge surveillance systems

15-12. Emergency department visits

15-33. Maltreatment and maltreatment fatalities of children

15-34. Physical assault by intimate partners

15-35. Rape or attempted rape

15-36. Sexual assault other than rape

15-37. Physical assaults

15-38. Physical fighting among adolescents

15-39. Weapon carrying by adolescents on school property

16\. Maternal, Infant, and Child Health

16-2. Child deaths

16-3. Adolescent and young adult deaths

16-4. Maternal deaths

16-5. Maternal illness and complications due to pregnancy

16-6. Prenatal care

16-14. Developmental disabilities

16-17. Prenatal substance exposure

16-18. Fetal alcohol syndrome

16-19. Breastfeeding

16-22. Medical homes for children with special health care needs

16-23. Service systems for children with special health care needs

20\. Occupational Safety and Health

20-5. Work-related homicides

20-6. Work-related assaults

20-7. Elevated blood lead levels from work exposure

20-9. Worksite stress reduction programs

23\. Public Health Infrastructure

23-1. Public health employee access to the Internet

23-2. Public access to information and surveillance data

23-3. Use of geocoding in health data systems

23-4. Data for all population groups

23-5. Data for Leading Health Indicators, Health Status Indicators, and
Priority Data Needs at Tribal, State, and local levels

23-6. National tracking of Healthy People 2010 objectives

23-7. Timely release of data on objectives

23-8. Competencies for public health workers

23-9. Training in essential public health services

23-10. Continuing education and training by public health agencies

23-11. Performance standards for essential public health services

23-12. Health improvement plans

23-13. Access to public health laboratory services

23-14. Access to epidemiology services

23-16. Data on public health expenditures

23-17. Population-based prevention research

25\. Sexually Transmitted Diseases

25-3. Primary and secondary syphilis

25-8. Heterosexually transmitted HIV infection in women

25-9. Congenital syphilis

25-10. Neonatal STDs

25-11. Responsible adolescent sexual behavior

25-12. Responsible sexual behavior messages on television

25-14. Screening in youth detention facilities and jails

25-15. Contracts to treat nonplan partners of STD patients

25-17. Screening of pregnant women

25-18. Compliance with recognized STD treatment standards

25-19. Provider referral services for sex partners

26\. Substance Abuse

26-7. Alcohol- and drug-related violence

26-8. Lost productivity

26-9. Substance-free youth

26-10. Adolescent and adult use of illicit substances

26-11. Binge drinking

26-12. Average annual alcohol consumption

26-13. Low-risk drinking among adults

26-14. Steroid use among adolescents

26-15. Inhalant use among adolescents

26-16. Peer disapproval of substance abuse

26-17. Perception of risk associated with substance abuse

26-18. Treatment gap for illicit drugs

26-22. Hospital emergency department referrals

26-23. Community partnerships and coalitions

## Terminology

(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.

## References

[^1]: Murray, C.J.L., and Lopez, A.D. *The Global Burden of Disease*.
    Cambridge, MA: Harvard University Press, 1996.

[^2]: Regier, D.A.; Narrow, W.; and Rae, D.S. Unpublished National
    Institute of Mental Health (NIMH) analyses, 1999.

[^3]: Regier, D.A.; Narrow, W.; Rae, D.S.; et al. The de facto U.S.
    mental and addictive disorders service system. Epidemiologic
    Catchment Area prospective 1-year prevalence rates of disorders and
    services. *Archives of General Psychiatry* 50:85-94, 1993.

[^4]: Kessler, R.C.; McGonagle, K.A.; Zhao, S.; et al. Lifetime and
    12-month prevalence of DSM-III-R psychiatric disorders in the U.S.
    *Archives of General Psychiatry* 51:8-19, 1994.

[^5]: Shaffer, D.; Fisher, P.; Dulcan, M.K.; et al. The NIMH Diagnostic
    Interview Schedule for Children, version 2.3 (DSIC 2.3):
    Description, acceptability, prevalence rates and performance in the
    Methods for the Epidemiology of Child and Adolescent Mental
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