Healthy People 2010Conference Edition

# 18 {#section .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 3](#goal)

[Overview 3](#overview)

[Issues 3](#issues)

[Trends 6](#trends)

[Disparities 8](#disparities)

[Opportunities 9](#opportunities)

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

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

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

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

[Treatment Expansion 16](#treatment-expansion)

[State Activities 21](#state-activities)

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

[Terminology 26](#terminology)

[References 27](#references)

### Objectives {#objectives .Heading-Special}

## 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 illness* is the term that refers collectively to all diagnosable
mental disorders. *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.

### 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 under-recognized. Today, 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 sexes, and all educational and
socioeconomic groups. Approximately 40 million Americans 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 (3 percent) in the past year.^2,\ 3,\ 4^ At least one in five
children and adolescents between ages 9 and 17 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 Americans 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,^10^
with the\
number of cases in the population doubling every 5 years of age after
age 60. 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^![](media/image1.wmf){width="4.497916666666667in"
height="5.9in"}

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.

-   *Schizophrenia* will affect more than 2 million Americans in one
    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.

-   *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^

-   *Anxiety disorders* encompass several discrete conditions, including
    panic disorder, obsessive-compulsive disorder, post-traumatic stress
    disorder, and phobia. More common than other mental disorders,
    anxiety disorders affect as many as 19 million Americans
    annually.^13^![](media/image2.wmf){width="4.498611111111111in"
    height="4.341666666666667in"}

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 and over 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 Americans
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 over 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.^19^

The direct costs of diagnosing and treating mental disorders totaled
approximately \$69 billion^17^ 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.^85^ 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.

### Trends

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 one 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.^20^ Comorbid mental and
addictive disorders also are evident in children and adolescents.^21^
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).^22^ 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.^23^ This time lag creates a window of
opportunity when prevention of substance abuse in these children may be
possible.^21^

As the life expectancy of Americans 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 U.S. 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. 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. 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.

### 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.^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.^24^ 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.^25,\ 26,\ 27^

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.^28,\ 29^ Women attempt
suicide more often than men,^30^ but men's risk of completed suicide is
on average 4.5 times higher than women's.^31^ This suicide gender gap
begins in adolescence and grows through middle and later life.^32^

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.^33^ 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.^34^

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.^35^ In any 1-year period, the number of
cases of major depression in persons aged 65 years and older is
approximately 1 percent, which is about half the rate among persons aged
45 to 64 years.^36^ Depression rates are much higher, however, among
older Americans who experience a physical health problem---12 percent
for persons hospitalized for problems such as hip fractures or heart
disease.^37^ Depression rates for older persons in nursing homes range
from 15 to 25 percent.^38^ 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.^39^ By age 85
years, the rate grows to 25 percent.^40^

In contrast, rates of primary psychotic disorders drop with age;^41^
thus, schizophrenia and persistent paranoid disorders affect fewer than
0.5 percent of older adults.^42^ Although fewer old persons attempt
suicide than do young persons,^43^ 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.^44^ Moreover, elderly white men
have a suicide rate six times the national average.^45^

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 ethnic

and racial 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
groups perceive mental illness. Behavioral problems that Western
medicine views as signs of mental illness may be assessed differently by
individuals in various ethnic and racial groups. With this caution in
mind, along with the recognition that sample sizes for ethnic and racial
groups may be limited, examination of existing large‑scale studies for
mental health trends among ethnic and racial groups of Americans 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.^46^

### 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,
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;
white men aged 65 and older began the decade at highest risk for suicide
(44.4), had declined below year 2000 target in 1994 (38.9) and had
declined further by 1997 to 35.5.

Note: Unless otherwise noted, data are from 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

  -----------------------------------------------------------------------
  **Number Objective**

  **Mental Health Status Improvement**

  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

  **Treatment Expansion**

  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

  **State Activities**

  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**: 6.0 suicide deaths per 100,000 population.

**Baseline:** 10.8 suicide deaths per 100,000 population in 1998
(preliminary data; age adjusted to the year 2000 standard population).

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

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

+------------------------------------------------+---------------------+
| **Total Population, 1997\***                   | **Suicide**         |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 11.4                |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 12.4                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 7.0                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 6.3                 |
+------------------------------------------------+---------------------+
| > White                                        | 12.3                |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 6.4                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 11.9                |
+------------------------------------------------+---------------------+
| > Black or African American                    | 6.5                 |
+------------------------------------------------+---------------------+
| > White                                        | 12.8                |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 4.4                 |
+------------------------------------------------+---------------------+
| > Male                                         | 19.4                |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 to 64 years)      |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 18.4                |
+------------------------------------------------+---------------------+
| > High school graduate                         | 18.9                |
+------------------------------------------------+---------------------+
| > At least some college                        | 10.2                |
+------------------------------------------------+---------------------+

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.

\*New data for population groups will be added when available.

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 among adolescents in
grades 9 through 12 in 1997.

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

**Data source:** Youth Risk Behavior Survey (YRBS), CDC, NCCDPHP.

+------------------------------------------------+---------------------+
| **Students in Grades 9 Through 12, 1997**      | **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                    | DNC                 |
+------------------------------------------------+---------------------+
| > White                                        | DNC                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 2.8                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 2.4                 |
+------------------------------------------------+---------------------+
| > White                                        | 2.0                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 3.3                 |
+------------------------------------------------+---------------------+
| > Male                                         | 2.0                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNA                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNA                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNA                 |
+------------------------------------------------+---------------------+

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

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 U.S. in 1996 and the third leading killer
of young persons between the ages of 15 and 24.^47,\ 48,\ 49,\ 50^ 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.

**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).^51^ New approaches developed over the
past 10 years provide ways to lower the number of persons who are
homeless who also have SMI. Using persistent patient outreach and
engagement strategies, service providers are helping homeless persons
with SMI connect with mainstream treatment systems.^52,\ 53^

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\
illnesses who are employed.

**Target:** 51 percent.

**Baseline:** 42 percent of persons aged 18 years and older with serious
mental illnesses were employed in 1994.

**Target setting method:** 21 percent improvement.

**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 severe
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.^54^ Employment also improves self-esteem and
independence; it helps a person to manage his or her own illness and
return to community life.^55,\ 56^ A majority of persons with SMI want
to be employed and rank employment as a primary personal goal.^57^
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.^57^

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^58^ 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.^59,\ 60^ Efforts are underway 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.^61^ Treatments using medications also have been tried,
both alone and in combination with "talking" therapy (unpublished data).
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.^62^ Risk for relapse seems to drop after 4 years of being
symptom free.^63^

### 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/primary care sector consists of health care
professionals such as internists, pediatricians, and nurse practitioners
in office-based practice, clinics, acute medical/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. ^3,\ 4^ 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, life‑long 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.^64,\ 65^

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.

Each year, over 100,000 youths are placed in juvenile justice
facilities.^66^ 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.^67,\ 68^
Screening activities, including parent or caregiver interviews, should
be conducted by qualified mental health personnel.^67^ 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 Treatment**  (unless      
                                                   noted)**     

                                                   Percent      

  **18-9a.**      Adults aged 18 to 54 years with  47 (1991)    55
                  serious mental illness                        

  **18-9b.**      Adults aged 18 years and older   23           50
                  with recognized depression                    

  **18-9c.**      Adults aged 18 years and older   60 (1984)    75
                  with schizophrenia                            

  **18-9d.**      Adults aged 18 years and older   38           50
                  with anxiety disorders                        
  --------------- -------------------------------- ------------ ------------

**Target setting method:** 17 percent improvement.

**Data sources**: Epidemiologic Catchment Area (ECA) Program, NIH,
NIMH;\
National Household Survey on Drug Abuse (NHSDA), SAMHSA, OAS; Mental
Health U.S., 1996, SAMHSA, CMHS.

+----------------------------+-----------+---------+--------+--------+
| **Adults Aged 18 Years and | **18-9a.\ | **      | **1    | **1    |
| Older Who Received\        | Serious\  | 18-9b.\ | 8-9c.\ | 8-9d.\ |
| Treatment for Mental\      | Mental    | Rec     | S      | A      |
| Disorders, 1997 (unless    | Illness   | ognized | chizop | nxiety |
| noted)**                   | (18 to 54 | Dep     | hrenia | Dis    |
|                            | years)    | ression | (1     | orders |
|                            | (1991)**  | (       | 984)** | (1     |
|                            |           | 1997)** |        | 997)** |
+============================+===========+=========+========+========+
|                            | 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     |
+----------------------------+-----------+---------+--------+--------+

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. ^68,\ 69,\ 70^ 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.^3^ 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. 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.^12,\ 24^ Treatment can alleviate each
of these problems. Available medications and psychological treatments,
alone or in combination, can help 80 percent of those with
depression.^72^

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.^73^ 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.^4^

**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.^75^

**Anxiety disorders** are not only common in the United States, but they
are ubiquitous across human cultures.^3,\ 4,\ 76^ Twenty-four percent of
the population will experience an anxiety disorder, many with
overlapping substance abuse disorders.^19,\ 77,\ 78^ 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.^79,\ 80,\ 81,\ 82^ Panic disorder and agoraphobia
are associated with increased risks of attempted and completed suicide.
^25,\ 83^

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.^3,\ 4^ The *lifetime* rates of
co-occurrence of mental disorders and addictive disorders are strikingly
high. About one in five Americans 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 serious mental illness 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 illnesses.

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

Nearly 700,000 persons with active symptoms of severe mental illness are
admitted to jails each year. They constitute about 7 percent of the jail
population.^84^ Individuals with SMI were over-represented 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.^85^ 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. ^85^

### 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:** 30 States.

**Baseline:** 10 States in 1998.

**Target setting method:** 200 percent improvement.

**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.^86^ 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.

Rehabilitation is an essential part of care for adults with severe
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.^54^ Employment also improves self‑esteem and
independence; it helps a person to manage his or her own illness and
return to community life. ^55,\ 56^ A majority of persons with SMI want
to be employed and rank employment as a primary personal goal.^57^
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. ^57^

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 (NRI/NASMHPD), 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.^87,\ 88,\ 89^ 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.^89,\ 90,\ 91,\ 92^ Hospitals have become the primary
mental health treatment site for a disproportionate number of African
Americans.^93,\ 94,\ 95,\ 96^

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.

**Target setting method:** Total coverage.

**Data source:** National Technical Assistance Center for State Mental
Health\
Systems (NRI/NASMHPD), 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.^38^ Older Americans
with clinically significant depressive symptoms range from 10 to 15
percent of the population.^97^ 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 preventive measures

  **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.               Children and youth with disabilities included in regular
                     education programs

  6-10.              Accessibility of health and wellness programs

  6-11.              Assistive devices and technology

  6-12.              Environmental barriers affecting participation

  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 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

  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 providers' communications 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

  16-15.             Prenatal substance exposure

  16-16.             Fetal alcohol syndrome

  16-19.             Breastfeeding

  16-22.             Medical home 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

  20-10.             Worksite stress reduction programs

  **23. Public       
  Health             
  Infrastructure**   

  23-1.              Public health employee access to 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              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
  ------------------ ---------------------------------------------------------------

##   {#section-1 .unnumbered}

## Terminology

(A listing of all abbreviations and acronyms used in this publication
appears in Appendix K.)

**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**: Depression is 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 can also be experienced in other
disorders, such as bipolar disorder (manic-depressive disorder).

**Diagnosable mental illness:** This term 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:** 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 that are
characterized by alterations in thinking, mood, or behavior (or some
combination thereof), that are all mediated by the brain and associated
with distress and/or impaired functioning. 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 races 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.

**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, grossly disorganized or catatonic behavior, and other symptoms.
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 18 years of age 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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