i,crccnt do (Breslau et al., 1998), but estimates are
higher for particular types of trauma. For women
,, ho are victims of crime, one study found the
ptcvalence of PTSD in a representative sample of
I\ omen to be 26 percent (Resnick et al., 1993). The
likelihood of developing PTSD is related to
p,-rtrauma vulnerability (in the form of genetic,
biological. and personality factors), magnitude of
the stressful event, preparedness for the event, and
rl,r quality of care after the event (Shalev, 1996).
The relative roles of biological, psychological,
or social factors also may vary across individuals
and across stages of the life span. In some people,
for example, depression arises primarily as a result
of exposure to stressful life events, whereas in
others the foremost cause of depression is genetic
predisposition.

Understanding Correlation, Causation,
and Consequences
(\ny discussion of the etiology of mental health and
tncntal illness needs to distinguish three key terms:
correlation, causation, and consequences. These
terms are often confused. All too frequently a
biological change in the brain (a lesion) is
purported to be the "cause" of a mental'disorder,
based on finding an association between the lesion
and a mental disorder. The fact is that any simple
association-or correlation-cannot and does not,
by itself, mean causation. The lesion could be a
correlate, a cause of, or an effect of the mental
disorder.

When researchers begin to tease apart etiology,
they usually start by noticing correlations. A
correlation is an association or linkage of two (or
more) events. A correlation simply means that the
events are linked in some way. Finding a
correlation between stressful life events and
depression would prompt more research on
causation. Does stress cause depression? Does
depression cause stress? Or are they both caused by
an unidentified factor? These would be the
questions guiding research. But, with correlational

The Fundamentals of Mental Health and Mental Illness

research, several steps are needed before causation
can be established.

If a correlational study shows that a stressful
event is associated with an increased probability
for depression and that the stress usually precedes
depression's onset, then stress is called a "risk
factor" for depression.5 Risk factors are biological,
psychological, or sociocultural variables that
increase the probability for developing a disorder
and antedate its onset (Garmezy, 1983; Werner &
Smith, 1992; Institute of Medicine [IOM], 1994a).
For each mental disorder, there are likely to be
multiple risk factors, which are woven together in
a complex chain of causation (IOM, 1994a). Some
risk factors may carry more weight than others, and
the interaction of risk factors may be additive or
synergistic.

Establishing causation of mental health and
mental illness is extremely difficult, as explained in
Chapter 1. Studies in the form of randomized,
controlled experiments provide the strongest
evidence of causation. The problem is that
experimental  research in humans  may be
logistically, ethically, or financially impossible.
Correlational research in humans has thus provided
much of what is known about the etiology of mental
disorders. Yet correlational research is not as
strong as experimental research in permitting
inferences about causality. The establishment of a
cause and effect relationship requires multiple
studies and requires judgment about the weight of
all the evidence. Multiple correlational studies can
be used to support causality, when, for example,
evaluating the effectiveness of clinical treatments
(Chambless et al., 1996). But, when studying
etiology, correlational studies are, if possible, best
combined with evidence of biological plausibility

s Chapter 4 contains a fuller discussion of the relationship between
stress and depression. In common parlance, stress refers either to the
stressful event or to the individual's response to the event. However,
mental health professionals distinguish the two by referring to the
external events as the "stressor" (or stressful life event) and to the
individual's response as the "stress response."

51


Mental Health: A Report of the Surgeon General

(IOM, 1994b).6 This means that correiational
findings should fit with biological, chemical, and
physical findings about mechanisms of action
relating to cause and effect.

Biological plausibility is often established in
animal models of disease. That is why researchers
seek animal models in which to study causation. In
mental health research, there are some animal
models-such as for anxiety and hyperactivity-but
a major problem is the difficulty of finding animal
models that simulate what is often uniquely human
functioning. The search for animal models,
however, is imperative.

Consequences are defined as the later outcomes
of a disorder. For example, the most serious
consequence of depression in older people is
increased mortality from either suicide or medical
illness (Frasure-Smith et al., 1993, 1995; Conwell,
1996; Penninx et al., 1998). The basis for this
relationship is not fully known. The relationship
between depression and suicide in adolescents is
presented in Chapter 3.

Putting this all together, the biopsychosocial
model holds that biological, psychological, or
social factors may be causes, correlates, and/or
consequences in relation to menial health and
mental illness. A stressful life event, such as
receiving the news of a diagnosis of cancer, offers
a graphic example of a psychological event that
causes immediate bi,ological changes and later has
psychological, biological, and social consequences.
When a patient receives news of the cancer
diagnosis, the brain's sensory cortex simultan-
eously registers the information (a correlate) and
sets in motion biological changes that cause the
heart to pound faster. The patient may experience
an almost immediate fear of death that may later
escalate to anxiety or depression. This certainly has
been established for breast cancer patients
(Farragher, 1998). Anxiety and depression are, in

' Other types of information used to establish cause and effect
relationships are the strength and consistency of the association,
time sequence information, dose-response relationships, and
disappearance of the effect when the cause is removed.

this case, consequences of the cancer diagnosis,'
although the exact mechanisms are not understood.
Being anxious or depressed may prompt further
changes in behavior, such as social withdrawal. So
there may be social consequences to the diagnosis
as well. This example is designed to lay out some
of the complexity of the biopsychosocial model
applied to mental health and mental illness.

Biological Influences on Mental Health
and Mental Illness

There are far-reaching biological and physical
influences on mental health and mental illness. The
major categories are genes, infections, physical
trauma, nutrition, hormones, and toxins (e.g., lead).
Examples have been noted throughout Chapter 1
and earlier in this chapter. This section focuses on
the first two categories-genes and infections-for
these are among the most exciting and intensive
areas of research relating to biological influences
on mental health and mental illness.

The Genetics of Behavior and Mental illness
That genes influence behavior, normal and
abnormal, has long been established (Plomin et al.,
1997). Genes influence behavior across the animal
spectrum, from the lowly fruitfly all the way to
humans. Sorting out which genes are involved and
determining how they influence behavior present
the greatest challenge. Research suggests that many
mental disorders arise in part from defects not in
single genes, but in multiple genes. However, none
of the genes has yet been pinpointed for common
mental disorders (National Institute of Mental
Health [NIMH], 1998).

The human genome contains approximately
80,000 genes that occupy approximately 5 percent
of the DNA sequences of the human genome. By
the spring of 2000, the human genome project will
have provided an initial rough draft version of the
entire sequence of the human genome, and in the

' Anxiety and depression may in some cases be caused by hormonal
changes related to the tumor itself.

52


The Fundamentals of Mental Health and Mental Illness

ensuing years, gaps in the sequence will be closed,
errors will be corrected, and the precise boundaries
\,f genes will be identified.

ln parallel, clinical medicine is studying the
;tgcregation of human disease in families. This
se
c'ffort includes the study of mental illness, most
notably schizophrenia, bipolar disorder (manic
depressive illness), early onset depression, autism,
mention-deficit/hyperactivity disorder, anorexia
uervosa. panic disorder, and a number of other
mental disorders (NIMH, 1998). From studying
how these disorders run in families, and from initial
molecular analyses of the genomes of these
families, we have learned that heredity-that `is,
genes-plays a role in the transmission of
vulnerability of all the aforementioned disorders
from generation to generation.

  But we have also learned that the transmission
of risk is not simple. Certain human diseases such
;LS Huntington's disease and cystic fibrosis result
from the transmission of a mutation-that is, a
rlclcteriously altered gene sequence-at one
location in the human genome. In these diseases, a.
single mutation has everything to say about whether
one will get the illness. The transmission of a trait
due to a single gene in the human genome is called
hlendelian transmission, after the Austrian monk,
(lrcgor Mendel, who was the first to develop
principles of modern genetics and who studied
traits due to single genes. When a single gene
determines the presence or absence of a disease or
other trait, genes are rather easy to discover on the
hasis of modern methods. Indeed, for almost all
hlrndelian disorders across medicine that affect
more than a few people, the genes already have
heen identified.

ln contrast to Mendelian disorders, to our
knowledge, all mental illnesses and all normal
variants of behavior are genetically complex. What
this means is that no single gene or even a
combination of genes dictates whether someone
\vill have an illness or a particular behavioral trait.
Rather. mental illness appears to result from the
interaction of multiple genes that confer risk, and

this risk is converted into illness by the interaction
of genes with environmental factors. The
implications for science are, first, that no gene is
equivalent to fate for mental illness. This gives us
hope that modifiable environmental risk factors can
eventually be identified and become targets for
prevention efforts. In addition, we recognize that
genes,  while significant  in their aggregate
contribution to risk, may each contribute only a
small increment, and, therefore, will be difficult to
discover. As a result, however, of the Human
Genome Project, we will know the sequence of
each human gene and the common variants for each
gene throughout the human race. With this
information, combined with modern technologies,
we will in the coming years identify genes that
confer risk of specific mental illnesses.
This information will be of the highest
importance for several reasons. First, genes are the
blueprints of cells. The products of genes, proteins,
work together in pathways or in building cellular
structures, so that finding variants within genes
will suggest pathways that can be targets of
opportunity for the development of new therapeutic
interventions. Genes will also be important clues to
what goes wrong in the brain when a disease
occurs. For example, once we know that a certain
gene is involved in risk of a particular mental
illness such as schizophrenia or autism, we can ask
at what time during the development of the brain
that particular gene is active and in which cells and
circuits the gene is expressed. This will give us
clues to critical times for intervention in a disease
process and information about what it is that goes
wrong. Finally, genes will provide tools for those
scientists who are searching for environmental risk
factors. Information from genetics will tell us at
what age environmental cofactors in risk must be
active,  and genes will help us identify
homogeneous populations for studies of treatment
and of prevention.

Heritability refers to how much genetics con-
tributes to the variation of a disease or trait in a
population at a given point in time (Plomin et al.,


Mental Health: A Report of the Surgeon General

1997). Once a disorder is established as running in
families, the next step is to determine its
heritability (see below), then its mode of
transmission, and, lastly, its location through
genetic mapping (Lombroso et al., 1994).
One powerful method for estimating heritability
is through twin studies.* Twin studies often
compare the frequency with which identical versus
fraternal twins display a disorder. Since identical
twins are from the same fertilized egg, they share
the exact genetic inheritance. Fraternal twins are
from separate eggs and thereby share only 50
percent of their genetic inheritance. If a disorder is
heritable, identical twins should have a higher .rate
of concordance-the expression of the trait by both
members of a twin pair-than fraternal twins. Such
studies, however, do not furnish information about
which or how many genes are involved. They just
can be used to estimate heritability. For example,
the heritability of bipolar disorder, according to the
most rigorous twin study, is about 59 percent,
although other estimates vary (NIMH, 1998). The
heritability of schizophrenia is estimated, on the
basis of twin studies, at a somewhat higher level
(NIMH, 1998).

Even with a high level of heritability, however,
it is essential to point out that environmental
factors (e.g., psychosocial environment, nutrition,
health care access) can play a significant role in the
severity and course of a disorder.
Another point is that environmental factors may
even protect against the disorder developing in the
first place. Even with the relatively high heritabili-
ty of schizophrenia, the median concordance rate
among identical twins is 46 percent' (NIMH, 1998),
meaning that in over half of the cases, the second

* Establishing that a disorder runs in families could suggest
environmental and/or genetic influences because families share
genes and environment. Comparing identical versus fraternal twins
assumes that their shared environments are about equal, thereby
providing insight about genetic influences. Such comparisons are
further enhanced by studies of twins (identical vs. fraternal)
separated at birth and adopted by different families.
9 The median concordance rate for identical twins is only 14 percent
(NIMH, 1998).

twin does not manifest schizophrenia even though
he or she has the same genes as the affected twin.
This implies that environmental factors exert a
significant role in the onset of schizophrenia.

Infectious Influences

It has been known since the early part of the 20th
century that infectious agents can penetrate into the
brain where they can cause mental disorders. A
highly common mental disorder of unknown
etiology at the turn of the century, termed "general
paresis," turned out to be a late manifestation of
syphilis. The sexually transmitted infectious
agent-Treponema  pallidurn-first caused
symptoms in reproductive organs and then,
sometimes years later, migrated to the brain where
it led to neurosyphilis. Neurosyphilis was manifest
by neurological deterioration (including psychosis),
paralysis,  and later death. With the wide
availability of penicillin after World War II,
neurosyphilis was virtually eliminated (Barondes,
1993).

Neurosyphilis may be thought of as a disease of
the past (at least in the developed world), but
dementia associated with infection by the human
immunodeficiency virus (HIV) is certainly not.
HIV-associated dementia continues to encumber
HIV-infected individuals worldwide. HIV infection
penetrates into the brain, producing a range of
progressive cognitive and behavioral impairments.
Early symptoms include impaired memory and
concentration, psychomotor slowing, and apathy.
Later symptoms, usually appearing years after
infection, include global impairments marked by
mutism, incontinence, and paraplegia (Navia et al.,
1986). The prevalence of HIV-associated dementia
varies, with estimates ranging from 15 percent to
44 percent of patients with HIV infection (Grant et
al., 1987; McArthur et al., 1993). The high end of
this estimate includes patients with subtle
neuropsychological  abnormalities.  What is
remarkable about HIV-associated dementia is that
it appears to be caused not by direct infection of
neurons, but by infection of immune cells known as

54


The Fundamentals of Mental Health and Mental Illness

lnacrophages that enter the brain from the blood.
The macrophages indirectly cause dysfunction and
death in nearby neurons by releasing soluble toxins
, Epstein & Gendelman, 1993).
Besides HIV-associated dementia and
neurosyphilis, other mental disorders are caused by
infectious agents. They include herpes simplex
encephalitis, measles encephalomyelitis, rabies
encephalitis, chronic meningitis, and subacute
,clerosing panencephalitis (Kaplan & Sadock,
1998). More recently, research has uncovered an
infectious etiology to one form of obsessive-
compulsive disorder, as explained below.

PANDAS

ln the late 198Os, it was discovered that some
children with obsessive-compulsive disorder (OCD)
experienced a sudden onset of symptoms soon after
;I streptococcal pharyngitis (Garvey et al., 1998).
The symptoms were classic for OCD-concerns
about contamination, spitting compulsions, and
extremely excessive hoarding-but the abrupt onset
was unusual. Further study of these children led to
the identification of a new classification of OCD
called PANDAS. This acronym stands for pediatric
:tutoimmune neuropsychiatric disorders associated
with streptococcal infection. PANDAS are distinct
from classic cases of OCD because of their
episodic clinical course marked by sudden
symptom exacerbation linked to streptococcal
infection, among other unique features. The
exacerbation of symptoms is correlated with a rise
in levels of antibodies that the child produces to
fight the strep infection. Consequently, researchers
proposed that PANDAS are caused by antibodies
against the strep infection that also manage to
attack the basal ganglia region of the child's brain
(Garvey et al., 1998). In other words, the strep
infection triggers the child's immune system to
develop antibodies, which, in turn, may attack the
child's brain, leading to obsessive and compulsive
behaviors. Under this proposal, the strep infection
does not directly induce the condition; rather, it

may do so indirectly by triggering antibody
formation. How the antibodies are so damaging to
a discrete region of the child's brain and how this
attack ignites OCD-like symptoms are two of the
fundamental questions guiding research.

Psychosocial Influences on Mental
Health and Mental Illness
This chapter thus far has highlighted some of the
psychosocial influences on mental health and
mental illness. Stressful life eyents, affect (mood
and level of arousal), personality, and gender are
prominent psychological influences. Social
influences include parents, socioeconomic status,
racial, cultural, and religious background, and
interpersonal relationships. These psychosocial
influences, taken individually or together, are
integrated into many chapters of this report in
discussions of epidemiology, etiology, risk factors,
barriers to treatment, and facilitators to recovery.
Since these psychosocial influences are familiar
to the general reader, detailed description of each
is beyond the scope of this section (with the
exception of cultural influences, which are
discussed in the Overview of Cultural Diversity and
Mental Health Services section). Instead, this
section summarizes the sweeping theories of
individual behavior and personality that inspired a
vast body of psychosocial research: psychodynamic
theories, behaviorism, and social learning theories.
The therapeutic strategies that arose from these
theories, and modifications necessary to make them
relevant to the changing demography of the U.S.
population,  are discussed in a later section,
Overview of Treatment.

Psychodynamic Theories
Psychodynamic theories of personality assert that
behavior is the product of underlying conflicts over
which people often have scant awareness. Sigmund
Freud (1856-1939) was the towering proponent of
psychoanalytic theory, the first of the 20th-century
psychodynamic theories. Many of Freud's


Mental Health: A Report of the Surgeon General

followers pioneered their own psychodynamic
theories,  but this section covers only
psychoanalytic theory.  A brief discussion of
Freud's work contributes to an historical
perspective of mental health theory and treatment
approaches.

Freud's theory of psychoanalysis holds two
major assumptions: (1) that much of mental life is
unconscious (i.e., outside awareness), and (2) that
past experiences, especially in early childhood,
shape how a person feels and behaves throughout
life (Brenner, 1978).

Freud's structural model of personality divides
the personality into three parts-the id, the ego,
and the superego. The id is the unconscious part
that is the cauldron of raw drives, such as for sex or
aggression. The ego, which -has conscious and
unconscious elements, is  the rational and
reasonable part of personality. Its role is to
maintain contact with the outside world in order to
help keep the individual in touch with society. As
such, the ego mediates between the conflicting
tendencies of the id and the superego. The latter is
a person's conscience that develops early in life
and is learned from parents, teachers, ahd others.
Like the ego, the superego has conscious and
unconscious elements (Brenner, 1978).
When all three parts of the personality are in
dynamic equilibrium, the individual is thought to
be mentally healthy. However, according to
psychoanalytic theory, if the ego is unable to
mediate between the id and the superego, an
imbalance would occur in the form of
psychological distress and symptoms of mental
disorders. Psychoanalytic theory views symptoms
as important only in terms of expression of
underlying conflicts between the parts of
personality. The theory holds that the conflicts
must be understood by the individual with the aid
of the psychoanalyst who would help the person
unearth the secrets of the unconscious. This was the
basis for psychoanalysis as a form of treatment, as
explained later in this chapter.

56

Behaviorism and Social learning Theory
Behaviorism (also called learning theory) posits
that personality is the sum of an individual's
observable responses  to the outside world
(Feldman, 1997). As charted by J. B. Watson and
h. F. Skinner in the early part of the 20th century,
behaviorism stands at loggerheads with
psychodynamic theories, which strive to understand
underlying conflicts. Behaviorism rejects the
existence of underlying conflicts and an
unconscious. Rather, it focuses on observable,
overt behaviors that are' learned from the
environment (Kazdin, 1996, 1997). Its application
to treatment of mental problems, which is discussed
later, is known as behavior modification.
Learning is seen as behavior change molded by
experience. Learning is accomplished largely
through either classical or operant conditioning.
Classical conditioning is grounded in the research
of Ivan Pavlov, a Russian physiologist. It explains
why some people react to formerly neutral stimuli
in their environment, stimuli that previously would
not have elicited a reaction. Pavlov's dogs, for
example, learned to salivate merely at the sound of
the bell, without any food in sight. Originally, the
sound of the bell would not have elicited salvation.
But by repeatedly pairing the sight of the food
(which elicits salvation on its own) with the sound
of the bell, Pavlov taught the dogs to salivate just
to the sound of the bell by itself.
  Operant conditioning, a process described and
coined by B. F. Skinner, is a form of learning in
which a voluntary response is strengthened or
attenuated, depending on its association with
positive or negative consequences (Feldman, 1997).
The strengthening of responses occurs by positive
reinforcement, such as food, pleasurable activities,
and attention from others. The attenuation or
discontinuation of responses occurs by negative
reinforcement in the form of removal of a
pleasurable stimulus. Thus, human behavior is
shaped in a trial and error way through positive and
negative reinforcement, without any reference to
inner conflicts or perceptions. What goes on inside


The Fundamentals of Mental Health and Mental Illness

the individual is irrelevant, for humans are equated
\vith "black boxes." Mental disorders represented
,,,llladaptive behaviors that were learned. They
Could be unlearned through behavior modification
,hehavior therapy) (Kazdin, 1996; 1997).
The movement beyond behaviorism was
<Pearheaded by Albert Bandura (1969, 1977), the
originator of social learning theory (also known as
\ocial cognitive theory). Social learning theory has
its roots in behaviorism, but it departs in a
,ignificant way. While acknowledging classical and
operant conditioning, social learning theory places
l'ar greater emphasis on a different type of learning,
particularly observational learning. Observational
learning occurs through selectively observing the
behavior of another person, a model. When the
behavior of the model is rewarded, children are
more likely to imitate the behavior. For example, a
child who observes another child receiving candy
for a particular behavior is more likely to carry out
similar behaviors. Social learning theory asserts
that people's cognitions-their views, perceptions,
and expectations toward their environment-affect
what they learn. Rather than being passively
conditioned by the environment, as behaviorism
proposed, humans take a more active role in
deciding what to learn as a result of cognitive
processing. Social learning theory gave rise to
cognitive-behavioral therapy, a mode of treatment
described later in this chapter and throughout this
report.

The Integrative Science of Mental Illness
and Health
Progress in understanding depression and schizo-
phrenia offers exciting examples of how findings
from different disciplines of the mental health field
have many common threads (Andreasen, 1997).
Despite the differences in terminology and
methodology, the results from different disciplines
have converged to paint a vivid picture of the
nature of the fundamental defects and the regions
of the brain that underlie these defects. Even in the
case of depression and schizophrenia, there is much

to be uncovered about etiology, yet the mental
health field is seen as poised "to use the power of
multiple disciplines." The disciplines are urged to
link together the study of the mind and the brain in
the search for understanding mental health and
mental illness (Andreasen, 1997).
This linkage already has been cemented
between cognitive psychology, behavioral
neurology, computer science, and neuroscience.
These disciplines have knit together the field of
"cognitive neuroscience'* (Kysslyn & Shin, 1992).
This new and joint discipline has carved out its
own professional society, journals (Waldrop,
1993), and textbooks (Gazzaniga et al., 1998).
There is movement toward integration of other
disciplines within the field. To promote linkages
between psychiatry and the neurosciences, neuro-
scientist Eric R. Kandel has furnished a novel
approach. His essay, "A New Intellectual Frame-
work for Psychiatry," supplies a set of biological
principles to forge a rapprochement-conceptual as
well as practical-between the two disciplines
(Kandel, 1998). Integrated approaches are seen as
vital to tackle the monumental complexity of
mental function.

Overview of Development,
Temperament, and Risk Factors
How we come to be the way we are is through the
process of development. Generally defined as the
lifelong process of growth, maturation, and change,
development is the product of the elaborate
interplay of biological, psychological, and social
influences. By studying development, researchers
hope to uncover the origins of both mental health
and mental illness.

This section elaborates and extends concepts
introduced above regarding the fundamental
workings of the brain at different developmental
stages. It then proceeds to explain several seminal
theories of development pioneered by Jean Piaget,
Erik Erikson, and John Bowlby. Their theories

cover  cognitive development, personality
development, and social development, respectively,

57


Mental Health: A Report of the Surgeon General

although there is some overlap. Their major works,
published in the 1950s and 196Os, were pivotal for
the psychological and social sciences, galvanizing
a huge body of theoretical and empirical research.
However, with the advancements of science and the
diversity of the population, these models may not
apply to all groups without some adaptation for
cultural context. The section concludes with a
reminder that the brain is the "great synthesizer" of
the many biological, psychological, and sociocul-
tural phenomena that make us who we are.

Physical Development

Physical development of the nervous system
provides the architecture for mental function
(cognition, mood, and intentional behavior). As can
be inferred from the discussion of brain complexity
in the introductory section, nervous system
development is arguably one of the most monu-
mentally complicated developmental achievements.
One hundred billion neurons must form elaborate
and precise arrays of interconnections. Neurons
begin the  developmental process as
undifferentiated cells,  cells so seemingly
anonymous that they are almost indistinguishable
from other cells in an embryo. On the basis of
genetic and epigenetic" influences, the cells must
first specialize, or differentiate, into neurons,
migrate to their final position, and then send their
growing axons (the branch of a neuron that
transmits impulses) to project over long distances
in order to form synapses with distant target cells
(Kandel et al., 1995).

Most neurobiologists are astounded at the level
of precision that neurons achieve in their
interconnections. The process of nervous system
development has been studied at increasingly
complex levels-molecular, cellular, tissue, and
behavioral levels. Yet, while researchers have
charted many of the behavioral milestones of
development because they are so amenable to

lo Epigenetic influences are those that arise from outside the genes
and lead to emergent, as opposed to predetermined, properties.

observation and analysis, far less is known about
molecular, cellular, and tissue interactions that
underlie them.

  Four overarching findings or organizing
principles have been gleaned from decades of
neuroscience research. The first finding is that the
formation of connections between neurons and their
target cells depends on axons growing along
anatomical pathways  that are studded with
signaling molecules, much like landing lights
illuminate the runway for a descending plane. The
second finding is that. an axon's reaching the
vicinity of, and locating, its correct target cell
depends on diffusable chemical signals being
transmitted from the target cell. The third finding
is that if an axon does not reach its correct target,
it is likely to die. This phenomenon, known as cell
death, or apoptosis, is so common that it affects up
to half of all developing neurons. The brain
overproduces the number of cells it needs, from
which it pares down to only the correct connections
(Kandel et al., 1995). Finally, neuron activity is
essential to strengthening the connections that are
formed. In other words, stimulation from the
environment-which is translated into neuron
activity-is vital for the forging of normal neural
development (Shatz, 1993; Kandel, 1995). This is
a fundamental principle that is revisited later in this
section. This principle helps to explain why, for
example, babies who are deprived of a stimulating
environment during their first year sometimes
suffer irreparable developmental effects.
  Behavior at birth consists of a repertoire of
simple reflexes, that is, inborn neurological
reactions that are involuntary in nature. Two
examples are the sucking reflex and the rooting
reflex," both of which are designed to ensure food
intake. Over time, the infant displays an expanded
repertoire of fine and gross -motor skills (e.g.,
crawling, walking) that begin to unfold in the first
few months and year of life. These include the

IL Newborns turn their head towards things-typically the
breast-that touch their cheek.

58


The Fundamentals of Mental Health and Mental Illness

,.herished ability to smile, which helps to solidify
;1 social bond with parents and caregivers. What
begins as a child's biological survival need for
food-evidenced by such behaviors as rooting and
I;uckin, o-can turn into a social, interpersonal
rsperience with the caregiver, as in the smile of an
infant at the sight of a nurturing parent. These
burgeoning motor capabilities are the forerunners
of more complex behavioral and mental functions,
but the actual relationships between early and later
abilities, and their molecular and cellular basis, are
understood only in the most rudimentary terms.

Theories of Psychological Development
Theories of human development are grounded in
the developmental perspective. The developmental
perspective takes into account the biological,
social, and psychological -environment; their
interaction; and their combined effect upon the
individual  throughout  the life span.
Developmentalist L. Breger (1974) proposes that
the developmental perspective incorporates three
key precepts:
o Behavioral maturation proceeds from the
simple to the complex;
o Future behaviors, whether temporally near or
distant, are a product of their antecedents (prior
responses to the developmental environment);
  and

o  The human response to a particular event or
experience often depends on the developmental
stage at which the experience occurs.
Each of these precepts is thought to apply to
nemobiological development, as well as behav-
ioral/psychosocial development, Moreover, each
has implications  for whether an individual
experiences either healthful or unhealthful
development that may lead to a mental disorder.
The three precepts are at the heart of each of
the  three  major  mainstream  theories of
developmental psychology that have guided
research and increased our understanding of both
normal and abnormal human development across
the life span. The following paragraphs offer brief

sketches of the developmental theories of Jean
Piaget, Erik Erikson, and John Bowlby; again, these
sketches are provided to afford the reader an
historical perspective of research on psychological
development.

Piaget: Cognitive Developmental Theory
Jean Piaget formulated one of the most influential
theories of cognitive development (Inhelder &
Piaget,  1958). Its focus was on cognitive
(intellectual) development, that is, the processes by
which children come to kno,w and understand the
world. Other aspects of human growth, both
physical and emotional, are beyond the scope of his
theory. Piaget posited that each step of cognitive
development proceeds from the previous step in a
fixed pattern, beginning at birth and ending in the
teen years.

Piaget had a seminal influence on the discipline
of cognitive psychology. Although empirical
research has called into question some of the
specifics of his theories, the broad outlines remain
widely accepted.

Erik frikson: Psychoanalytic Developmental
Theory
The psychoanalytic theory of development is best
exemplified in the work of Erik Erikson, a
psychoanalyst who expanded upon Freud's original
theories of psychosexual development. One of
Erikson's pioneering contributions was that
development unfolded throughout the life span, a
view that has become widely embraced.

Freud postulated that development proceeded
through a series of stages in which children seek
pleasure or gratification from a particular body part
(i.e., the oral, anal, and phallic stage). In contrast,
Erikson's theories of child development focus on
the interrelationship between a developing child's
internal psychosexual development and his or her
more external emotional development, emphasizing
the interpersonal relationships that arise between
the child and parents (Erikson, 1950).

59


Mental Health: A Report of the Surgeon General

Erikson conceived of the life course, from birth
to old age, as a series of eight epigenetic stages
that, as other developmental theories, proceed in a
stepwise fashion, the next dependent upon how
well the previous has been mastered: trust versus
mistrust; autonomy versus shame and doubt;
initiative versus guilt; industry versus inferiority;
identity versus role diffusion; intimacy versus
isolation; generativity versus stagnation; ego
integrity versus despair.

Erikson portrayed each stage as a crisis or
conflict that needed resolution, either at the time or
at a subsequent stage. Each successive stage
presents its own challenges but, at the same time,
offers the opportunity for correction of unresolved
challenges of previous stages. At each stage the
tension was between the psychosocial and
psychosexual-the outward-looking versus inward-
looking perspectives. Psychopathology, in the form
of a mental disorder, would arise if a stage was
ultimately not mastered successfully.
Over the years, Erikson's theory has had great
heuristic value to guide theorists and practitioners
in organizing their approach to mental health and
mental illness. However, his theory does not readily
lend itself to empirical scrutiny. His theory also has
been criticized as reflecting the concerns of male
European culture (where Erikson was born and
trained before moving to the United States) rather
than those of women and other cultures. The need
for cultural sensitivity and competence is discussed
later in this chapter.

John Bow/by: Attachment Theory of
Development
Fifty years ago, a new conceptualization of the
psychoanalytic approach to development came into
the lexicon of human development theory. John
Bowlby's reinterpretation of Freudian development
is grounded in both Darwinian evolutionary theory
and animal ethology. The previous work of Konrad
Lorenz and others, who explored the relationship
between other animals and their caregivers,
determined that the bonds of infant care and the

attachment of young to their caregivers are seminal
in the drive for survival. Similarly, Bowlby
theorized that for humans, attachment to a
caregiver had a biological basis in the need for
survival (Bowlby, 195 1). Moreover, he suggested
that this attachment drive exists alongside the drive
for nutrition and the sex drive, yet distinct and
separate from them. Attachment is seen as the
anchor that enables the developing child to explore
the world.

With the comfort and security of a stable and
routine attachment to the mother-or other primary
caregiver-a child is abk to organize other
elements of development in a coherent way. In
contrast, instability in the caregiving relation-
ship-whether physical distance, erratic patterns of
parental behavior, or even physical or emotional
abuse-may interfere with the sense of trust and
security, potentially giving rise to anxiety and
psychological problems later in childhood or even
decades later in life.

Nature and Nurture: The Ultimate
Synthesis
For over a century, an intense debate among
developmentalists and other scientists has pitted
nature (genetic  inheritance) against nurture
(environment) as the engine of human development
and behavior. Francis Galton, a 19th-century
geneticist and cousin of Charles Darwin, declared
that "there is no escape from the conclusion that
nature prevails enormously over nurture" (cited in
Plomin, 1996). As the debate raged, either nature or
nurture gained ascendancy. During the 1940s and
195Os, for example, behaviorism held sway over
American psychology with its argument that
nurture was preeminent.

The pendulum now is coming to rest with the
recognition that behavior is the product of both
nature  and nurture (Plomin, 1996). Each
contributes to the development of mental health and
mental illness. Nature and nurture are not
necessarily independent forces but can interact with

60


,,,,r' another: nature can influence nurture, and
,,urture can influence nature (Plomin, 1996).

Studies comparing identical and fraternal twins
I,a,s shed light on the contributions of nature and

Ilurwre.  These studies show that for many
b,l,avioral traits, as well as mental disorders, there
,, :, noticeable heritable component (see earlier
,li>sussion of heritability). Yet even with the most
l,ighlY heritable traits or conditions, identical twins
,( lro share the same genetic endowment display
,n;trked differences. Identical twins, for example,
;,rc concordant for schizophrenia in 46 percent of
ll;iirs (NIMH, 1998), meaning that more than 50
llcrcent of pairs are not concordant. Something yet
utlkt~own about the environment protects against
the development of schizophrenia in genetically
itlcntical individuals (Plomin, 1996).

  How do nature and nurture interact? This
ilucstion cannot be directly answered by twin
\tudies. Animal models have proven to be fertile
IFround for study of the mechanisms-at the
?
niolecular and cellular level-by which nature and
nurture interact. As reviewed earlier, research in
different animal models has established that the
environment can alter the structure andfunction of
the central nervous system (Baily & Kandel, 1993).
This holds true not only during early development,
but also into adulthood. Nurture influences nature,
right down to detectable changes in the brain.

During development of the nervous system,
each neuron forms myriad intricate synaptic
connections with other neurons, the outcome of the
interaction of genes and the environment described
above. In this case, the environment is a very
general term-it denotes the local extracellular
environment surrounding the growing neuron, as
well as what we traditionally think of as the
environment (sensory environment, psychosocial
environment, diet, etc.). When a neuron forms a
synapse with its target cell, the pattern of activity,
usually furnished by external environmental
stimulation, strengthens or weakens the developing
synapse. Only strengthened synaptic connections
survive early development to form enduring

connections, while weakened synaptic connections
are eliminated (Shatz, 1993; Kandel et al., 1995).
For example, kittens deprived of visual experience
early in life sustain permanent disruption to
synapses in parts of their visual cortex (Hubel &
Wiesel, 1970).

  Later in the course of development, established
patterns of connections still can be altered by the
environment-through learning. Studies in a
variety of animal models have found that certain
forms of learning lead to changes in the structure
and function of neurons. With long-term
                          .

memory-the long-term storage of learned
information-these changes take the form of an
enhanced number of synaptic connections and
increased gene expression (Kandel et al., 1995).
Increased gene expression appears to be for
synthesis of new proteins needed for the structural
changes occurring at the synapse (Bailey & Kandel,
1993).

Researchers continue to probe for changes in
the brain associated with mental disorders. They
have found, for instance, that repeated stress from
the environment affects the hippocampus, an area
of the brain located deep within the cerebral
hemispheres. Research in animals has shown that
repeated stress triggers atrophy of dendrites of
certain types of neurons in a segment of the
hippocampus (Sapolsky, 1996; McEwen, 1998).
Similarly, imaging studies in humans suggest that
stress-related disorders (e.g., post-traumatic stress
disorder) induce possibly irreversible atrophy of
the hippocampus (McEwen & Magarinos, 1997).
Anxiety disorders  also alter neuroendocrine
systems (Sullivan et al., 1998). These are some of
the tantalizing ways in which nurture influences
nature.

The mental health field is far from a complete
understanding of the biological, psychological, and
sociocultural bases of development, but develop-
pment clearly involves interplay among these
influences. Understanding the process of develop-
ment requires knowledge, ranging from the most
fundamental level-that of gene expression and

The Fundamentals of Mental Health and Mental Illness

61


Mental Health: A Report of the Surgeon General

interactions between molecules and cells-all the
way up to the highest levels of cognition, memory,
emotion, and language. The challenge requires
integration of concepts from many different
disciplines. A fuller understanding of development
is not only important in its own right, but it is
expected to pave the way for our ultimate
understanding of mental health and mental illness
and how different factors shape their expression at
different stages of the life span.

Overview of Prevention
The field of public health has long recognized the
imperative of prevention to contain a major health
problem (IOM, 1,988). The principles of pre-
vention were first applied to infectious diseases in
the form of mass vaccination, water safety, and
other forms of public hygiene. As successes
amassed, prevention came to be applied to other
areas of health, including chronic diseases (IOM,
1994a). A landmark report published by the
Institute of Medicine in 1994 extended the concept
of prevention to mental disorders (IOM, 1994a).
Reducing Risks for Mental Disorders evaluated the
body of research on the prevention of mental
disorders, offered new definitions of prevention,
and provided recommendations on Federal policies
and programs, among other goals.
Preventing an illness from occurring is
inherently better than having to treat the illness
after its onset. In many areas of health, increased
understanding of etiology and the role of risk and
protective factors in the onset of health problems
has propelled prevention. In the mental health field,
however, progress has been slow because of two
fundamental and interrelated problems: for most
major mental disorders, there is insufficient
understanding about etiology and/or there is an
inability to alter the known etiology of a particular
disorder. While these have stymied the develop-
ment of prevention interventions, some successful
strategies have emerged in the absence of a full
understanding of etiology.

Rigorous scientific trials have documented
successful prevention programs in such areas as
dysthymia and major depressive disorder (Munoz et
al., 1987; Clarke et al., 1993, conduct problems
(Berrento-Clement et al.,  1984), and risky
behaviors leading to HIV infection (Kalichman et
al., in press) and low birthweight babies (Olds et
al., 1986). Much progress also has been made to
prevent the occurrence of lead poisoning, which, if
unchecked, can lead to serious and persistent
cognitive deficits in children (Centers for Disease
Control and Prevention, 1991; Pirkle et al., 1994).
Lastly, historical milestones' in prevention of
mental illness led to the successful eradication of
neurosyphilis, pellagra, and measles encephalo-
myelitis (measles invasion of the brain) in the
developed world.

Definitions of Prevention
The term "prevention" has different meanings to
different people. It also has different meanings to
different fields of health. The classic definitions
used in public health distinguish between primary
prevention, secondary prevention, and tertiary
prevention (Commission on Chronic Illness, 1957).
Primary prevention is the prevention of a disease
before it occurs; secondary prevention is the
prevention of recurrences or exacerbations of a
disease that already has been diagnosed; and
tertiary prevention is the reduction in the amount of
disability caused by a disease to achieve the highest
level of function.

The Institute of Medicine report on prevention
identified problems in applying these definitions to
the mental health field (IOM, 1994a). The problems
stemmed mostly from the difficulty of diagnosing
mental disorders and from shifts in the definitions
of mental disorders over time (see Diagnosis of
Mental Illness). Consequently, the Institute of
Medicine redefined prevention for the mental
health field in terms of three core activities:
prevention, treatment, and maintenance (IOM,
1994a). Prevention, according to the IOM report, is
similar to the classic concept of primary prevention

62


t'rc,lll public health: it refers to interventions to
,\ard off the initial onset of a mental disorder.
Ire,tment refers to the identification of individuals
,t irh mental disorders and the standard treatment
tar those disorders, which includes interventions to
reduce the likelihood of future co-occurring
disorders. And maintenance refers to interventions
,llat are oriented to reduce relapse and recurrence
;,,,d to provide rehabilitation.  (Maintenance
incorporates what the public health field
tmditionally defines as some forms of secondary
aIld all forms of tertiary prevention.)
The Institute of Medicine's new definitions .of
prevention have been very important in
conceptualizing th'e nature of prevention activities
for mental disorders; however, the terms have not
yet been universally adopted by mental health
rusearchers. As a result, this report strives to use
the terms employed by the researchers themselves.
To avoid confusion, the report furnishes the
rclcvant definition along with study descriptions.
When the term "prevention" is used in this
report withour a qualifying term, it refers to the
prevention of the initial onset of a mental disorder
or emotional or behavioral problem,. including
prevention of comorbidity. First onset corresponds
to the initial point in time when an individual's
mental health problems meet the full criteria for a
diagnosis of a mental disorder.

Risk Factors and Protective Factors
The concepts of risk and protective factors, risk
reduction, and enhancement of protective factors
(also sometimes referred to as fostering resilience)
are central to most empirically based prevention
Programs. Risk factors are those characteristics,
variables, or hazards that, if present for a given
individual, make it more likely that this individual,
rather than someone selected at random from the
general population,  will develop a disorder
(Garmezy, 1983; Werner & Smith, 1992; TOM,
1994a). TO qualify as a risk factor the variable must
antedate the onset of the disorder. Yet risk factors
are not static. They can change in relation to a

The Fundamentals of Mental Health and Mental Illness

developmental phase or a new stressor in one's life,
and they can reside within the individual, family,
community, or institutions. Some risks such as
gender and family history are fixed; that is, they are
not malleable to change. Other risk factors such as
lack of social support, inability to read, and
exposure to bullying can be altered by strategic and
potent interventions (Coie & Krehbiel, 1984;
Silverman, 1988; Olweus, 1991; Kellam & Rebok,
1992). Current research is focusing on the interplay
between biological risk factors and psychosocial
risk factors and how they can be modified. As
explained earlier, even with' a highly heritable
condition such as schizophrenia, concordance
studies show that in over half of identical twins, the
second twin does not have schizophrenia. This
suggests the possibility of modifying the
environment to eventually prevent the biological
risk factor (i.e., the unidentified genes that
contribute to schizophrenia) from being expressed.
  Prevention not only focuses on the risks
associated with a particular illness or problem but
also on protective factors. Protective factors
improve a person's response to some environmental
hazard resulting in an adaptive outcome (Rutter,
1979). Such factors, which can reside with the
individual or within the family or community, do
not necessarily foster normal development in the
absence of risk factors, but they may make an
appreciable difference on the influence exerted by
risk factors (IOM, 1994a). There is much to be
learned in the mental health field about the role of
protective factors across the life span and within
families as well as individuals. The potential for
altering these factors in intervention studies is
enormous. The construct of "resilience" is related
to the concept of protective factors, but it focuses
more on the ability of a single individual to
withstand chronic stress or recover from traumatic
life events. There are many different perceptions of
what constitutes resilience or "competence,"
another related term. Despite the increasing
popularity of these ideas, "virtually no intervention

63


Mental Health: A Report of the Surgeon General

studies have been conducted that test the outcomes
of resilience variables" (Grover, 1998).
  Preventive researchers use risk status to
identify populations for intervention, and then they
target risk factors that are thought to be causal and
malleable and target protective factors that are to
be enhanced. If the interventions are successful, the
amount of risk decreases, protective factors
increase,  and the likelihood of onset of the
potential problem also decreases. The risks for
onset of a disorder are likely to be somewhat
different from the risks involved in relapse of a
previously diagnosed condition. This is an
important distinction because at-risk terminology is
used throughout the mental health intervention
spectrum. The optimal treatment protocol for an
individual with a serious mental condition aims to
reduce the length of time the disorder exists, halt a
progression of severity, and halt the recurrence of
the original disorder, or if not possible, to increase
the length of time between episodes (IOM, 1994a).
To do this requires an assessment of the
individual's specific risks for recurrence.
  Many mental health problems, especially in
childhood, share some of the same risk factors for
initial onset, so targeting those factors can result in
positive outcomes in multiple areas. Risk factors
that are common to many disorders include
individual factors such as neurophysiological
deficits, difficult temperament, chronic physical
illness, and below-average intelligence; family
factors such as severe marital discord, social
disadvantage, overcrowding or large family size,
paternal criminality, maternal mental disorder, and
admission into foster care; and community factors
such as living in an area with a high rate of
disorganization and inadequate schools (IOM,
1994a). Also, some individual risk factors can lead
to a state of vulnerability in which other risk
factors may have more effect. For example, low
birthweight is a general risk factor for multiple
physical and mental outcomes; however, when it is
combined with a high-risk social environment, it
more consistently has poorer outcomes (McGauhey

et al., 1991). The accumulation of risk factors
usually increases the likelihood of onset of
disorder, but the presence of protective factors can
attenuate this to varying degrees.

The concept of accumulation of risks in
pathways that accentuate other risks has led
prevention researchers to the concept of "breaking
the chain at its weakest links" (Robins, 1970; IOM,
1994a). In other words, some of the risks, even
though they contribute significantly to onset, may
be less malleable than others to intervention. The
preventive strategy is to change the risks that are
most easily and quickly amen$ble to intervention.
For example, it may be easier to prevent a child
from being disruptive and isolated from peers by
altering his or her classroom environment and
increasing academic achievement than it is to
change the home environment where there is severe
marital discord and substance abuse.

  Because mental health is so intrinsically
related to all other aspects of health, it is
imperative when providing preventive interventions
to consider the interactions of risk and protective
factors, etiological links across domains, and
multiple outcomes. For example, chronic illness,
unemployment, substance abuse, and being the
victim of violence can be risk factors or mediating
variables for the onset of mental health problems
(Kaplan et al., 1987). Yet some of the same factors
also can be related to the consequences of mental
health problems (e.g., depression may lead to
substance abuse, which in turn may lead to lung or
liver cancer).

Overview of Treatment

Introduction to Range of Treatments
Mental disorders are treatable, contrary to what
many think.12 An armamentarium of efficacious
treatments is available to ameliorate symptoms. In

I2 About 40 percent of those surveyed thought that they "didn't think
anyone could help" as a reason for not seeking mental health
treatment (Sussman et al., 1987).

64


The Fundamentals of Mental Health and Mental Illness

t`a,.t. for most mental disorders, there is generally
not just one but a range of treatments of proven
CificXv. Most treatments fall under two general
i2tegories. psychosocial and pharmacologicaLi
\loreover. the combination of the two-known as
,nultimodal therapy-can sometimes be even more
<ffective than each individually (see Chapter 3).
The evidence for treatment being more effective
Ihan placebo is overwhelming, as documented in
[he main chapters of this report (Chapters 3 through
5). The degree of effectiveness tends to vary,
depending on the disorder and the target population
cc'.g.. older adults with depression). What is
t,ptimnl for one disorder and/or age group may not
he optimal for another. Further, treatments
generally need td be tailored t'o the client and to
client preferences.

The inescapable point is that studies
demonstrate conclusively that treatment is more
effective than placebo. Placebo (an inactive formof
treatment) in both pharmacological and psycho-
therapy studies has a powerful effect in its own
right. as this section later explains. Placebo is more
cffcctive than no treatment. Therefore, to capitalize
on the placebo response, people are encouraged to
\cck treatment, even if the treatment is not as
optimal as that described in this report.

If tmmnent is so effective, then why are so few
prqle receiving it ? Studies reveal that less than
one-third of adults with a diagnosable mental
disorder, and even a smaller proportion of children,
receive any mental health services in a given year.
This section of the chapter strives to explain why
by examining the types of barriers that prevent
People from seeking help. But the chapter first
covers some general points about psychological and
Pharmacological therapies. It also discusses why
therapies that work so well in research settings do
not work as well in practice.

mer treatments are electroconvulsive therapy (Chapters 4 and 5) and
wne types of surgery.

Psychotherapy

Psychotherapy is a learning process in which
mental health professionals seek to help individuals
who have mental disorders and mental health
problems. It is a process that is accomplished
largely by the exchange of verbal communication,
.hence it often is referred .to as "talk therapy."
Many of the theories undergirding each orientation
to psychotherapy were summarized earlier in this
chapter.

Participants in psychotherapy can vary in age
from the very young to the very old, and problems
can vary from mental health problems to disabling
and catastrophic mental disorders. Although people
often are seen individually, psychotherapy also can
be done with couples, families, and groups. In each
case, participants present their problems and then
work with the psychotherapist to develop a more
effective means of understanding and handling
their problems. This report focuses on individual
psychotherapy and also mentions couples therapy
and various forms of family interventions,
particularly psycho-educational approaches.
Although not discussed in the report, group
psychotherapy is effective for selected individuals
with some mood disorders, anxiety disorders,
schizophrenia, personality disorders, and for mental
health problems seen in somatic illness (Yalom,
1995; Kanas, in press).

  Estimates of the number of orientations to
psychotherapy vary from a very small number to
well over 400. The larger estimate generally refers
to all the variations of the three major orientations,
that is, psychodynamic, behavioral, and humanistic.
Each orientation falls under the more general
conceptual category of either action or reflection.

Psychodynamic orientations are the oldest.
They place a premium on self-understanding, with
the implicit (or sometimes explicit) assumption that
increased self-understanding will produce salutary
changes in the participant. Behavioral orientations
are geared toward action, with a clear attempt to
mobilize the resources of the patient in the
direction of change, whether or not there is any


Mental Health: A Report of the Surgeon General

understanding of the etiology of the problem.
Humanistic orientations aim toward increased self-
understanding, often in the direction of personal
growth, but use treatment techniques that often are
much more active than are likely to be employed by
the psychodynamic clinician.

While the following paragraphs focus on
psychodynamic, behavioral, and humanistic
orientations, they also discuss interpersonal therapy
and cognitive-behavioral therapy as outgrowths of
psychodynamic and behavioral therapy, respect-
ively. Psychodynamic, interpersonal, and cognitive-
behavioral therapy are most commonly the focus of
treatment research reported throughout this report.

Psychodynamic Therapy

The first major approach to psychotherapy was
developed by Sigmund Freud and is called
psychoanalysis (Horowitz, 1988). Since its origin
more than a century ago, psychoanalysis has
undergone many changes. Today, Freudian (or
classical) psychoanalysis is still practiced, but
other variations have been developed-ego
psychology, object relations theory, interpersonal
psychology, and self-psychology, each of which
can be grouped under the general term
"psychodynamic" (Horowitz, 1988). The
psychodynamic therapies, even though they differ
somewhat in theory and approach, all have some
concepts in common. With each, the role of the past
in shaping the present is emphasized, so it is
important, in understanding behavior, to understand
its origins and bow people come to act and feel as
they do. A second critical concept common to all
psychodynamic approaches is the belief in the
unconscious, so that there is much that influences
our behavior of which we are not aware. This
makes the process of understanding more difficult,
as we often act for reasons that we cannot state, and
these reasons often are linked to previous
experiences.  Thus,  an important part of
psychodynamic psychotherapy is to make the
unconscious conscious or to help the patient

understand the origin of actions that are troubling
so that they can be corrected.
For some psychodynamic approaches, such as
the classical Freudian approach, the focus is on the
individual and the experiences the person had in the
early years that give shape to current behavior,
.even beyond the awareness of the patient. For
other, more contemporary approaches, such as
interpersonal therapy,  the focus is on the
relationship between the person and others. First
developed as a time-limited treatment for midlife
depression, interpersonal therapy focuses on grief,
role disputes, role transitions, and interpersonal
deficits (Klerman et al., 1984). The goal of
interpersonal therapy is to improve current
interpersonal skills. The therapist takes an active
role in teaching patients to evaluate their
interactions with others and to become aware of
self-isolation and interpersonal difficulties. The
therapist also offers advice and helps the patient to
make decisions.

Behavior Therapy

A second major approach to psychotherapy is
known as behavior modification or behavior
therapy (Kazdin, 1996,1997). It focuses on current
behavior rather than on early patterns of the
patient. In its earlier form, behavior therapy dealt
exclusively with what people did rather than what
they thought or felt. The general principles of
learning were applied to the learning of maladap-
tive as well as adaptive behaviors. Thus, if a person
could be conditioned to act in a functional way,
there was no reason why the same principles of
conditioning could not be employed to help the
person unlearn dysfunctional behavior and learn to
replace it with more functional behavior. The role
of the environment was very important for behavior
therapists, because it provided the positive and
negative reinforcements that sustained or
eliminated various behaviors. Therefore, ways of
shaping that environment to make it more
responsive to the needs of the individual were
important in behavior therapy.

66


More recently, there has been a significant
,ddition to the interests and activities of behavior
therapists. Although behavior continued to be
itnportant in relation t0 reinforcements, Cog-
nitions- what the person thought about, perceived,
or interpreted what was transpiring-were also
seen as important. This combined emphasis led to
a therapeutic  variant known as cognitive-
b~j~a\~ioral therapy, an approach that incorporates
cognition with behavior in understanding and
altering the problems that patients present (Kazdin,
1996).

Cognitive-behavioral therapy draws on
behaviorism as well as cognitive psychology,. a
field devoted to the scientific study of mental
processes,  such as perceiving, remembering,
reasoning, decisionmaking, and problem solving.
The use of cognition in cognitive-behavioral
therapy varies from attending to the role of the
environment in providing a model for behavior, to
the close study of irrational beliefs, to the
importance of individual thought processes in
constructing a vision of the surrounding world. In
each case, it is critical to study what the individual
in therapy thinks and does and less important to
understand the past events that led to that,pattern of
thinking and doing. Cognitive-behavioral therapy
strives to alter faulty cognitions and replace them
with thoughts and self-statements that promote
adaptive behavior (Beck et al., 1979). For instance,
cognitive-behavioral therapy tries to replace self-
defeatist expectations ("I can't do anything right")
with positive expectations ("I can do this right").
Cognitive-behavioral therapy has gained such
ascendancy as a means of integrating cognitive and
behavioral views of human functioning that the
field is more frequently referred to as cognitive-
behavioral therapy rather than behavior therapy
(Kazdin, 1996).

Humanis tic Therapy

The third wave of psychotherapy is referred to
variously as humanistic (Rogers, 1961), existential
(Yalom, 1980), experiential, or Gestalt therapy. It

owes its origins as a treatment to the client-
centered therapy that was originated by Carl
Rogers,  and the theory can be traced to
philosophical roots beginning with the 19th century
philosopher, Soren Kierkegaard. The central focus
of humanistic therapy is the immediate experience
of the client. The emphasis is on the present and the
potential for future development rather than on the
past, and on immediate feelings rather than on
thoughts or behaviors. It is rooted in the everyday
subjective experience of the person seeking
assistance and is much less concerned with mental
illness than it is with human growth.
One critical aspect of humanistic treatment is
the relationship that is forged between the
therapist, who in some ways serves as a guide in an
exploration of self-discovery, and the client, who is
seeking greater knowledge of the self and an
expansion of inherent human potential. The focus
on the self and the search for self-awareness is akin
to psychodynamic psychotherapy, while the
emphasis on the present is more similar to behavior
therapy.

Although it is possible to describe distinctive
orientations to psychotherapy, as has been done
above, most psychotherapists describe themselves
as eclectic in their practice, rather than as adherents
to any single approach to treatment. As a result,
there is a growing development referred to as
"psychotherapy integration" (Wolfe & Goldfried,
1988). It strives to capture what is best about each
of the individual approaches. Psychotherapy
integration includes various attempts to look
beyond the confines of any single orientation but
rather to see what can be learned from other
perspectives. It is characterized by an openness to
various ways of integrating diverse theories and
techniques. Psychotherapy also should be modified
to be culturally sensitive to the needs of racial and
ethnic minorities (Acosta et al., 1982; Sue et al.,
1994; Lopez, in press).

The scientific evidence on efficacy presented in
this report, however, is focused primarily on
specific, standardized forms of psychotherapy.

The Fundamentals of Mental Health and Mental Illness

67


Mental Health: A Report of the Surgeon General

Pharmacological Therapies
The past decade has seen an outpouring of new
drugs introduced for the treatment of mental
disorders (Nemeroff, 1998). New medications for
the treatment of depression and schizophrenia are
among the achievements stoked by research
advances in both neuroscience and molecular
biology. Through the process known as rational
drug design, researchers have become increasingly
sophisticated at designing drugs by manipulating
their chemical structures. Their goal is to create
more effective therapeutic agents, with fewer side
effects,  exquisitely targeted to correct the
biochemical alterations that accompany mental
disorders.

The process was not always so rational. Many
of the older pharmacotherapies (drug treatments)
that had been introduced -by 1960 had been
discovered largely by accident. Researchers
studying drugs for completely different purposes
serendipitously found them to be useful for treating
mental disorders (Barondes, 1993). Thanks to their
willingness to follow up on unexpected leads, drugs
such as chlorpromazine (for psychosis), lithium
(for bipolar disorder), and imipramine (for
depression) became available. The `advent of
chlorpromazine in 1952 and other neuroleptic drugs
was so revolutionary that it was one of the major
historical forces behind the deinstitutionalization
movement that is discussed later in this chapter.
The past generation of pharmacotherapies, once
shown to be safe and effective, was introduced to
the market generally before their mechanism of
action was understood. Years of research after their
introduction revealed how many of them work
therapeutically. Knowledge about their actions has
had two cardinal consequences: it helped probe the
etiology of mental disorders, and it ushered in the
next generation of pharmacotherapies that are more
selective in their mechanism of action.

Mechanisms of Action

The mechanism of action refers to how a
pharmacotherapy interacts with its target in the

body to produce therapeutic effects. Pharma-
cotherapies that act in similar ways are grouped
together into broad categories (e.g., stimulants,
antidepressants). Within each category are several
chemical classes. The individual pharmacotherapies
within a chemical class share similar chemical
structures. Table 2-9 presents several common
categories and classes, along with their indication,
that is, their clinical use.

Many pharmacotherapies for mental disorders
have as their initial action the alteration-either
increase or decrease-in the amount of a
neurotransmitter. Neurotransmitter levels can be
altered by pharmacotherapies in myriad ways:
pharmacotherapies can mimic the action of the
neurotransmitter in cell-to-cell signaling; they can
block the action of the neurotransmitter; or they
can alter its synthesis, breakdown (degradation),
release, or reuptake, among other possibilities
(Cooper et al., 1996).

Neurotransmitters generally are concentrated in
separate brain regions and circuits. Within the cells
that form a circuit, each neurotransmitter has its
own biochemical pathway for synthesis,
degradation, and reuptake, as well as its own
specialized molecules known as receptors. At the
time of neurotransmission, when a traveling signal
reaches the tip (terminal) of the presynaptic cell,
the neurotransmitter is released from the cell into
the synaptic cleft. It migrates across the synaptic
cleft in less than a millisecond and then binds to
receptors situated on the membrane of the
postsynaptic cell. The neurotransmitter's binding to
the receptor alters the shape of the receptor in such
a way that the neurotransmitter can either excite the
postsynaptic cell, and thereby transmit the signal to
this next cell, or inhibit the receptor, and thereby
block signal transmission. The neurotransmitter's
action is terminated either by enzymes that degrade
it right there, in the synaptic cleft, or by transporter
proteins that return unused neurotransmitter back to
the presynaptic neuron for reuse, a "recycling"
process known as reuptake. The widely prescribed
class of antidepressants referred to as the selective

68


The Fundamentals of Mental Health and Mental Illness

fable 2-g. Selected types of pharmacotherapies
--
Categov and Class
AntipsychotiCS (neuroleptics)
Typical antipsychotics*
Atypical antipsychotics*'

Example(s) of Clinical Use

Schizophrenia, psychosis

Antidepressants
Selective serotonin
  reuptake inhibitors
Tricyclic and heterocyclic
  antidepressants'**
Monoamine oxidase inhibitors

Depression, anxiety

Stimulants

Antimanic
Lithium
Anticonvulsants
Thyroid supplementation

Attention-deficit/hyperactivity disorder

Mania

Antianxiety (anxioiytics)
Benzodiazepines
Antidepressants
p-Adrenergic-blocking drugs

Anxiety

Cholinesterase inhibitors
~~

Alzheimer's disease

* Also known as first-generation antipsychotics, they include these chemical classes: phenothiazines (e.g., chlorpromazine),
butyrophenones (e.g., haloperidol), and thioxanthenes (Dixon et al., 1995).
*' Also known as second-generation antipsychotics, they include these chemical classes: dibenzoxazepine (e.g., clozapine),
thienobenzodiazepine (e.g., olanzapine), and benzisoxazole (e.g., risperidone).

*** Include imipramine and amitriptyline.

Source: Perry et al., 1997

\erotonin reuptake inhibitors primarily block the
Lrction of the transporter protein for serotonin, thus
leaving more serotonin to remain at the synapse
(Schloss & Williams, 1998). Depression is thought
to be reflected in decreased serotonin transmission,
so one rationale for this class of antidepressants is
to boost the level of serotonin (see Chapter 4).

Although the effects of reuptake inhibitors on
neurotransmitter concentrations in the synapse
occur with the first dose, therapeutic benefit
typically lags behind by days or weeks. This
observation has spurred considerable recent
research on chronic and "downstream" actions of
psychotropics, particularly antidepressants. For
example, in  animal models the repeated
administration of nearly all antidepressants is
associated with a reduction in the number of

postsynaptic p receptors, so-called down-regulation
that parallels the time course of clinical effect in
patients (Schatzberg & Nemeroff, 1998). Some of
the secondary effects of reuptake inhibitors may be
mediated by the activation of intraneuronal "second
messenger" proteins  which result from the
stimulation of postsynaptic receptors (Schatzberg
& Nemeroff, 1998).

Receptors for each transmitter come in
numerous varieties. Not only are there several types
of receptor for each neurotransmitter, but there may
be many subtypes. For serotonin, for example, there
are seven types of receptors, designated 5-HT,-5-
HT,, and seven receptor subtypes, totaling 14
separate receptors (Schatzberg & Nemeroff, 1998).
The pace at which receptors are identified has

69


Mental Health: A Report of the Surgeon General

become so dizzying that these figures are likely to
be obsolete by the time this paragraph is read.
A pharmacotherapy typically interacts with a
receptor in either one of two ways-as an agonist
or as an antagonist.14 When a pharmacotherapy acts
as an agonist, it mimics the action of the natural
neurotransmitter. When a pharmacotherapy acts as
an antagonist, it inhibits, or blocks, the neuro-
transmitter's action, often by binding to the
receptor and preventing the natural transmitter from
binding there. An antagonist disrupts the action of
the neurotransmitter.

The diversity of receptors presents vast
opportunities for drug development. Through
rational drug design, pharmacotherapies have
become increasingly selective in their actions.
Generally speaking,  the more selective the
pharmacotherapy's action, the more targeted it is to
one receptor rather than another, the narrower its
spectrum of action, and the fewer the side effects.
Conversely, the broader the pharmacotherapy's
action, the less targeted to a receptor type or
subtype, the broader the effects, and the broader the
side effects (Minneman, 1994). However, the
interaction among neurotransmitter systems in the
brain renders some of the apparent distinctions
among medications more apparent than real. Thus,
despite differential initial actions on neuro-
transmitters, both serotonin and norepinephrine
reuptake blockers have similar biochemical effects
after chronic dosing (Potter et al., 1985).

Complementary and Aiterna tive Treatment
Recent interest in the health benefits of a plethora
of natural products has engendered claims related
to putative effects on mental health. These have
ranged from reports of enhanced memory in people
taking the herb, ginseng, to the use of the St. John's
wort flowers as an antidepressant (see Chapter 4).

There are major challenges to evaluating the
role of complementary and alternative treatments in

" There are certainly exceptions to this general rule. Some
pharmacotherapies work as partial agonists and partial antagonists
simultaneously.

maintaining mental health or treating mental
disorders. In many cases, preparations are not
standardized and consist of a variabIe mixture of
substances, any of which may be the active
ingredient(s). Purity, bioavailability, amount and
timing of doses,  and other factors that are
standardized for traditional pharmaceutical agents
prior to testing cannot be taken for granted with
natural products. Current regulations in the United
States classify most complementary and alternative
treatments as "food supplements," which are not
subject to premarketing approval of the Food and
Drug Administration.         .

At present, no conclusions about the role, if
any, of complementary and alternative treatments
in mental health or illness can be accepted with
certainty, as very few claims or studies meet
acceptable scientific standards. With funding from
government and private industry, controlled clinical
trials are under way, including the use of St. John's
wort (Hypericum perforutum) as a treatment for
depression, and omega-3 fatty acids (fish oils) as a
mood stabilizer in bipolar depression. In addition,
it is important for clinicians and investigators to
account for any herbs or natural products being
taken by their patients or research subjects that
might interact with traditional treatments.

Issues in Treatment

The foregoing section has furnished an overview of
the types and nature of mental health treatment.
The resounding message, which is echoed
throughout this report, is that a range of efficacious
treatments is available. The following material
deals with four issues surrounding treatment-the
placebo response, benefits and risks, the gap be-
tween how well treatments work in clinical trials
versus in the real world, and the constellation of
barriers that hinder people from seeking mental
health treatment.

Placebo Response
Recognized since antiquity, the placebo effect
refers to the powerful role of patients' attitudes and

70


The Fundamentals of Mental Health and Mental Illness

perceptions that help them improve and recover
from health problems. Hippocrates established the
therapeutic principle of physicians laying their
hands in a reassuring manner to draw on the inner
resources  of the patient to fight disease.
Technically speaking, the placebo effect refers to
treatment responses in the placebo group, responses
that cannot be explained on the basis of active
treatment (Friedman et al., 1996a). A placebo is an
inactive treatment, either in the form of an inert pill
for studying a new drug treatment or an inactive
procedure for studying a psychological therapy.
The effects of active treatment are often compared
with a control group that receives a pharm-
acological or psychological placebo,
It is not unusual for a placebo effect to be found
in up to 50 percent of patients in any study of a
medical treatment (Schatzberg& Nemeroff, 1998).
For example, about 30 percent of patients typically
respond to a placebo in a clinical trial of a new
antidepressant (see Chapter 4). The rate is even
higher for an antianxiety agent (an anxiolytic)
(Schweizer & Rickels, 1997). The placebo effect is
of such import that a placebo group or other control
group'* is mandated by the Food and Drug
Administration in clinical trials of a new
pharmacotherapy to establish its efficacy prior to
marketing (Friedman et al., 1996a). If the
pharmacotherapy is not statistically superior to the
control, efficacy cannot be established. It is
somewhat more difficult to fashion an analog of an
inert pill in the testing of new and experimental
psychological therapies. Psychological studies can
employ a "psychological" placebo in the form of a
treatment known to be ineffectual. Or they can
employ a comparison group, which receives an
alternative psychological therapy. Some treatment
studies employ both a "psychological" placebo, as
well as a comparison group.`6

I5 when it is unethical to deprive patients of treatment, such as the
case with AIDS, conventional treatment is given as the control.
" The criteria developed by a division of the American
Psychological Association for establishing treatment efficacy call
for the experimental treatment to be statistically superior to "pill or

The basis of the placebo response is not fully
known, but there are thought to be many possible
reasons. These reasons, which relate to attributes of
the disorder or the disease, the patient, and the
treatment setting, include spontaneous remission,
personality variables (e.g., social acquiescence),
patient expectations, attitudes of and compassion
by clinicians, and receiving treatment in a
specialized setting (Schweizer & Rickels, 1997). In
studies of postoperative pain, the placebo response
is mediated by patients' production of endogenous
pain-killing substances known as endorphins
(Levine et al., 1978).

Benefits and Risks

Throughout this report, currently accepted
treatments for mental disorders will be described.
Except where otherwise indicated, the efficacy of
these interventions has been documented in
multiple controlled, clinical trials published in the
peer-reviewed literature. In some cases, these have
been supplemented by expert consensus reports or
practice guidelines.

Most studies of efficacy of specific treatments
for mental disorders have been highly structured
clinical trials, performed on individuals with a
single disorder, in good physical health. While
necessary and important, these trials do not always
generalize easily to the wider population, which
includes many individuals whose mental disorder is
accompanied by another mental or somatic disorder
and/or alcohol or substance abuse, and who may be
taking other medications. Moreover, children,
adolescents, and the elderly are excluded from
many clinical trials,"  as are those in certain
settings, such as nursing homes. Newer, more
generalizable studies are being undertaken to

psychological placebo or to another treatment" (Chambless et al.,
1998).
I7 In March 1998, the NIH issued a policy guideline stating that
NM-funded investigators will be expected to include children in
clinical trials, which normally would involve adults only, when
there is sound scientific rationale and in the absence of a strong
justification to the contrary.

71


Mental Health: A Report of the Surgeon General

address these shortcomings of the scientific
literature (Lebowitz & Rudorfer, 1998).
Pending the results of these newer studies, it is
important, for clinical decisionmakers to review the
current best evidence for the efficacy of treatments.
People with mental disorders and their health
providers should consider all possible options and
carefully weigh the pros and cons of each, as well
as the possibility of no treatment at all, before
deciding upon a course of action. Such an informed
consent process entails the calculation of a
"benefit-to-risk ratio" for each available treatment
option. Most medications or somatic treatments
have side effects, for example, but a likelihood of
significant clinical benefit often overrides side-
effects in support of a treatment recommendation.

Gap Between Efficacy and Effectiveness
Mental health professionals have long observed
that treatments work better in the clinical research
trial setting as opposed to typical clinical practice
settings. The diminished level of treatment
effectiveness in real-world settings is so
perceptible that it even has a name, the "efficacy-
effectiveness gap." Efficacy is the term for what
works in the clinical trial setting, and effectiveness
is the term for what works in typical clinical
practice settings. The efficacy-effectiveness gap
applies to both pharmacological therapies and to
psychotherapies (Munoz et al., 1994; Seligman,
1995). The gap is not unique to mental health, for
it is found with somatic disorders too.
The magnitude of the gap can be surprisingly
high. With schizophrenia medications, one review
article found that, in clinical trials, the use of
traditional antipsychotic  medications for
schizophrenia was associated with an average
annual relapse rate of about 23 percent, whereas the
same medications used in clinical practice carried
a relapse rate of about 50 percent (Dixon et al.,
1995). The magnitude of the gap found in this study
may not apply to other medications and other
`disorders, much less to psychological therapies.
Studies of real-world effectiveness are scarce. Yet

some degree of gap is widely recognized. The
question is, why?

Efficacy studies test whether treatment works
under ideal circumstances. They typically exclude
patients with other mental or somatic disorders. In
the past, they typically have examined relatively
homogeneous populations, usually white males.
Furthermore, efficacy studies are carried out by
highly trained specialists following strict protocols
that require frequent patient monitoring. Finally,
participation in efficacy studies is often free of
charge to patients.

  It is not surprising that the reasons commonly
cited to explain the discrepancy between efficacy
and effectiveness focus on the practicalities and
constraints imposed by the real world. In real-world
settings, patients often are more heterogeneous and
ethnically diverse, are beset by comorbidity (more
than one mental or somatic disorder),i8 are often
less compliant, and are seen more often in general
medical rather than specialty settings; providers are
less inclined to adequately monitor and standardize
treatment; and cost pressures exist on both patients
and providers, depending on the nature of the
financing of care (Dixon et al., 1995; Wells &
Sturm, 1996). This constellation of real-world
constraints appears to explain the gap.

Barriers to Seeking Help

Most people with mental disorders do not seek
treatment, according to figures presented in the
next section of this chapter and in Chapter 6. This
general statement applies to adults and older adults
and to parents and guardians who make treatment
decisions for children with mental disorders. There
is a multiplicity of reasons why people fail to seek
treatment for mental disorders but few detailed
studies. The barriers to treatment fall under several
umbrella categories: demographic factors, patient
attitudes toward a service system that often

I* Having a second disorder increases the possibility of drug
interactions, which may translate into reduced dosing. Comorbidity
is discussed throughout this report.


neglects the special needs of racial and ethnic
minorities, financial, and organizational.
Several demographic factors predispose people
against seeking treatment. African Americans,
Hispanics (Sussman et al., 1987; Gallo et al.,
1995), and poor women (Miranda & Green, 1999)
are less inclined than non-Hispanic
whites-particularly females-to seek treatment.
Common patient attitudes that deter people from
seeking treatment are not having the time, fear of
being hospitalized, thinking that they could handle
it alone, thinking that no one could help, and
stigma (being too embarrassed to discuss the
problem) (Sussman et al., 1987). Above all, the
cost of treatment is the most prevalent deterrent to
seeking care, according to a large study of
community residents (Sussman et al., 1987). Cost
is a major determinant of seeking treatment even
among people with health insurance because of
inferior coverage of mental health as compared
with health care in general. Finally, the
organizational barriers include fragmentation of
services and lack of availability of services
(Horwitz, 1987). Members of racial and ethnic
minority groups often perceive that services offered
by the existing system do not or will not meet their
needs, for example, by taking into account their
cultural or linguistic practices. These particular
barriers are discussed in greater depth with respect
to minority groups (later in this chapter) and with
respect to different ages (Chapters 3 to 5).
  Demographic, attitudinal, financial, and
organizational barriers operate at various points
and to various degrees. Seeking treatment is
conceived of as a complex process that begins with
an individual or parent recognizing that thinking,
mood, or behaviors are unusual and severe enough
to require treatment; interpreting symptoms as a
"medical" or mental health problem; deciding
whether or not to seek help and from whom;
receiving care; and, lastly, evaluating whether
continuation of treatment is warranted (Sussman et
al., 1987).

Overview of Mental Health Services
Over the past three centuries, the complex
patchwork of mental health services in the United
States has become so fragmented that it is referred
to as the defacto menraE health system (Regier et
al., 1993b). Its shape has been determined by many
heterogeneous factors rather than by a single
guiding set of organizing principles. The de facto
system has been characterized as having distinct
sectors, financing, duration of care, and settings
(see Figure 2-4).

The four sectors of the system are the specialty
mental health sector, the geberal medical/primary
care sector, the human services sector, and the
voluntary support network sector. Specialty mental
health services include services provided by
specialized mental health professionals (e.g..
psychologists, psychiatric nurses, psychiatrists, and
psychiatric social workers) and the specialized
offices, facilities, and agencies in which they work.
Specialty services were designed expressly for the
provision of mental health services. The general
medical/primary care sector consists of health care
professionals (e.g., family physicians, nurse
practitioners, internists, pediatricians, etc.) and
the settings (i.e., offices, clinics, and hospitals) in
which they work. These settings were designed for
the full range of health care services, including, but
not specialized for, the delivery of mental health
services. The human services sector consists of
social welfare, criminal justice, educational,
religious, and charitable services. The voluntary
support network refers to self-help groups and
organizations. These are groups devoted to
education, communication, and support, all of
which extend beyond formal treatment.
Financing of the de facto system refers to the
payer of services. The system is often described as
being divided into a public (i.e., government) and
a private sector. The term "public sector" refers
both to services directly operated by government
agencies (e.g., state and county mental hospitals)
and to services financed with government resources

The Fundamentals of Mental Health and Mental Illness

73


Mental Health: A Report of the Surgeon General

Figure 2-4. The mental health service system

ical/Primafy Care
ces . -(
pport Network J i .- '

(e.g., Medicaid, a Federal-State program for
financing health care services for people who are
poor and disabled, and Medicare, a Federal health
insurance program primarily for older Americans
and people who retired early due to disability).
Publicly financed services may be provided by
private organizations. The term "private sector"
refers both to services directly operated by private
agencies and to services financed with private
resources (e.g., employer-provided insurance).
  The duration of care is divided between
services for the treatment of acute conditions and
those devoted to the long-term care of chronic (i.e.,
severe and persistent) conditions, such as
schizophrenia, bipolar disorder, and Alzheimer's
disease. The former, provided in psychiatric
hospitals, psychiatric units in general hospitals, and
in beds "scattered" in general hospital wards,

includes brief treatment-oriented services. Long-
term care includes residential care as well as some
treatment services. Residential care is often
referred to as "custodial," when supervised living
predominates over active treatment.
The settings for care and treatment include
institutional, community-based, and home-based.
The former refers to facilities, particularly public
mental hospitals and nursing homes, which usually
are seen by patients and families as large,
regimented, and impersonal. They often are
removed from the community by distance and
frequency of contact with friends and family. In
contrast, community-based services are close to
where patients or clients live. Services are typically
provided by community agencies and organizations.
Home-based services include informal supports
provided in an individual's residence.

74


The Fundamentals of Mental Health and Mental Illness

Chapter 6 examines the impact of recent
changes in financing and organizing services on
access and quality of care. Many of these issues
also are addressed in Chapters 3 to 5, where they
are discussed in the context of care and treatment at
each stage of the life cycle. The following material
provides general information on current patterns of
use and focuses on the historical origins of mental
health services.

Overall Patterns of Use

According to recent national surveys (Regier et al,
1993b; Kessler et al., 1996), a total of about 15
percent of the U.S. adult population use mental
health services in any given year. Eleven percent
receive their services from either the general
medical care sector or the specialty mental health
sector, in roughly equal proportions. In addition,
about 5 percent receive care from the human
services sector, and about 3 percent receive care
from the voluntary support network. (The overlap
across these latter two sectors accounts for these
figures totaling more than 15 percent.)
Slightly more than half of the 15 percent of the
adult population that use mental health services
have a diagnosable mental or addictive disorder (8
percent), while the remaining portion has a mental
health problem (7 percent). Bearing in mind that 28
percent of the population have a diagnosable
mental or substance abuse disorder, only about
one-third with a diagnosable mental disorder
receives treatment in 1 year (Figure 2-5). In short,
this transjates to the majority of those with
a diagnosable mental disorder not receiving
treatment.

Similarly, about 21 percent of the child and
adolescent population use mental health services
annually. Nine percent ieceive care from the health
care sector, almost exclusively from the specialty
mental health sector. Seventeen percent of the child
and adolescent population receive care from the
human services sector, mostly in the school system,
yet there is much overlap with the health sector
(again accounting for the sum being more than 21

percent). The distribution of those who do and do
not currently meet diagnostic criteria for. a mental
disorder is similar to that for adults (Figure 2-6).

History of Mental Health Services
The history of mental health services in the United
States has been chronicled by historian Gerald N.
Grob in a series of landmark books from which this
account is drawn (Grob, 1983, 1991, 1994). The
origins of the mental health services system
coincide with the colonial settlement of the United
States. Individuals with mental illness were cared
for at home until urbanization induced state
governments`to confront a problem that had been
relegated largely to families. The states' response
was to build institutions, known first as asylums
and later as mental hospitals. When the
Pennsylvania Hospital opened in Philadelphia in
the mid- 18th century, it had provisions for
individuals with mental illness housed in its
basement: Also in the mid-18th century, colonial
Virginia was the first state to build an asylum for
mentally ill citizens, which it constructed in its
capital at Williamsburg. If not cared for at home or
in asylums, those with mental illness were likely to
be found in jails, almshouses, work houses, and
other institutions. By the time of the Revolutionary
War, the beginnings were in place for each of the
four sectors of the de facto mental health system.
  The origins of treatment for mental illness in
the general medical/primary care sector can be
traced to the Pennsylvania Hospital. The origins of
specialty mental health care can be traced to the
Williamsburg asylum. Home care, the most
common response to mental illness, probably
became a part of the voluntary support network,
whereas the human services sector was by far the
most common organized or institutional response,
by placing individuals in almshouses (homes for
the poor) and work houses. The first form of treat-
ment-known as "moral treatment"-was not given
until the very end of the 18th century, after the
Revolutionary War.

75