Mental Health: A Report of the Surgeon General

However,  it must be emphasized that group
probabilities do not necessarily speak to individual

cases.

Etiology of Schizophrenia

The cause of schizophrenia has not yet been
determined, although research points to the interaction
of genetic endowment and major environmental
upheaval during development of the brain. This section
first discusses genetic studies and then turns to the
evidence for neurodevelopmental disruption. These
lines of research are beginning to converge:
neurodevelopmental disruption may be the result of
genetic and/or environmental stressors early in
development, leading to subtle alterations in the brain.
Furthermore,  environmental factors later in
development can either exacerbate or ameliorate
expression of genetic or neurodevelopmental defects.
The overarching message is that the onset and course of
schizophrenia are most likely the result of an
interaction between genetic and environmental
influences.

Current research proposes that schizophrenia is
caused by a genetic vulnerability coupled with
environmental and psychosocial stressors, the so-called
diathesis-stress model (Zubin & Spring, 1977; Russo et
al., 1995; Portin & Alanen, 1997). Family studies
suggest that people have varying levels of inherited
genetic vulnerability, from very low to very high, to
schizophrenia. Whether or not the person develops
schizophrenia is partly determined by this vulnerability.
At the same time, the development of schizophrenia
also depends on the amount and types of stresses the
person experiences over time. An a@ogy can be drawn
to diabetes by virtue of both genetic factors (e.g.,
family history) and behavioral factors (e.g., diet,
exercise, stress) that interact to determine whether or
not a given person develops diabetes. How the
interaction works in schizophrenia is unknown, yet the
subject of ongoing research (Murray et al., 1992;
Spaulding, 1997; Jones & Cannon, 1998; van OS &
Marcelis, 1998).

Family, twin, and adoption studies support the role
of genetic influences in schizophrenia (Kendler &
Diehl, 1993; McGuffin et al., 1995; Portin & Alanen,
1997). Immediate biological relatives of people with
schizophrenia have about 10 times greater risk than that
of the general population. Given prevalence estimates,
this translates into a 5 to 10 percent lifetime risk for
first-degree relatives (including children and siblings)
and suggests a substantial genetic component to
schizophrenia (e.g., Kety, 1987; Tsuang et al., 1991;
Cannon et al., 1998). What also bolsters a genetic role
are findings that the identical twin of a person with
schizophrenia is at greater risk than a sibling or
fraternal twin, and that adoptive relatives do not share
the increased risk of biological relatives (see Figure
4-3). However, in about 40 percent of identical twins
in which one is diagnosed with schizophrenia, the other
never meets the diagnostic criteria. The discordance
among identical twins clearly indicates that environ-
mental factors likely also play a role (DSM-IV).

276

Despite the evidence for genetic vulnerability to
schizophrenia, scientists have not yet identified the
genes responsible (Kendler & Diehl, 1993; Levinson et
al., 1998). The current consensus is that multiple genes
are responsible (Kendler et al., 1996; Kunugi et al.,
1996, 1997; Portin & Alanen, 1997; Straub et al.,
1998).

  Numerous brain abnormalities have been found in
schizophrenia. For example, patients often have
enlarged cranial ventricles (cavities in the brain that
transport cerebrospinal fluid), especially the third
ventricle (Weinberger, 1987; Schwarzkopf et al., 199 1;
Woods & Yurgelun-Todd, 1991; Dykes et al., 1992;
Lieberman et al., 1993; DeQuardo et al., 1996), and
decreased cerebral size (Schwarzkopf et al., 1991;
Ward et al., 1996) compared with control groups.
Several studies suggest this may be more common
among men (Nopoulos et al., 1997) whose families do
not have a history of schizophrenia (Schwarzkopf et al.,
1991; Vita et al., 1994). There is also some evidence
that at least some people with schizophrenia have
unusual cortical laterality, with dysfunction localizing


:

Adults and Mental Health

J"..e 7 -.  . . . . . . -. "".-..Mp,.mJ ""..,l"p...-.,.".

-12.5%    General population
3rd-degree
relatives     First cousins

           Uncles/Aunts

m 25%
Znd-degree
relatives


m 50%
1 St-degree
relatives


m 100%




ienes shared

Nephews/Nieces

`Grandchildren

Half siblings

Parents

Siblings

Children

Fraternal twins

Identical twins



Relationship to
person with
schizophrenia

                      48%
                     I
0    10 20 30 40 50

Risk of developing schizophrenia

            Source: Q Gotbsman (1991).

i

to the left hemisphere (Braun et al., 1995). To explain   This is perhaps related to unusual neuronal density
laterality, some have proposed a prenatal injury or   (Selemon et al., 1998) and may be more prevalent
insult at the time of left hemisphere development,   among patients whose families have a history of
which normally lags behind that of the right   schizophrenia than those whose do not (Sautter et al.,
hemisphere (Bracha, 1991).              1995). However, mapping patients' symptoms with
  The anatomical abnormalities found in different   brain regions is complex and variable. Researchers
parts of the brain tend to correlate with schizophrenia's   believe that the dysfunctions are present in brain
positive symptoms (Barta et al., 1990; Shenton et al.,   circuitry rather than in one or two localized areas of the
1992, Bogerts et al., 1993; Wible et al., 1995) and   brain (Andreasenet al., 1997,1998; Wiser et al., 1998).
negative symptoms (Buchanan et al., 1993). Positive     Excessive levels of the neurotransmitter dopamine
symptoms are often linked to temporal lobe   have long been implicated in schizophrenia, although
dysfunction, as shown by imaging studies that utilize   it is unclear whether the excess is a primary cause of
blood flow and glucose metabolism. Such dysfunction   schizophrenia or a result of a more fundamental
possibly is related to abnormal phospholipid   dysfunction. More recent evidence implicates much
metabolism (Fukuzako et al., 1996). Disorganized   greater complexity in the dysregulation of dopamine
speech (taken to reflect disorganized thinking) has been   and other neurotransmitter systems (Grace, 1991,1992;
associated with abnormalities in brain regions   Olie & Bayle, 1997). Some of this research ties
associated with speech regulation (McGuire et al.,   schizophrenia to certain variations in dopafine
1998). Negative and cognitive symptoms, especially   receptors (Nakamura et al., 1995; Serretti et al., 1998),
those related to volition and planning, are commonly   while other research focuses on the serotonin system
associated with prefrontal lobe dysfunction (Capleton,   (Inayama et al., 1996). However, it must be emphasized
1996; Abbruzzese et al., 1997; Mattson et al., 1997).   that in many cases it is possible that perturbations in

277


Mental Health: A Report of the Surgeon General

neurotransmitter systems  may  result from
complications of schizophrenia, or its treatment, rather
than from its causes (Csemansky & Grace, 1998).
  The "stressors" investigated in schizophrenia
research include a wide range of biological,
environmental, psychological, and social factors. There
is consistent evidence that prenatal stressors are
associated with increased risk of the child developing
schizophrenia in adulthood, although the mechanisms
for these associations are unexplained. Some
interesting preliminary research suggests risk factors
include maternal prenatal poverty (Cohen, 1993), poor
nutrition (Susser & Lin, 1992; Susser et al., 1996,
1998), and depression (Jones et al., 1998). Other
stressors are exposure to influenza outbreaks (Mednick
et al., 1988; Adams et al., 1993; Rantakallio et al.,
1997), war zone exposure (van OS &Selten, 1998), and
Rh-factor incompatibility (Hollister, 1996). Their
variety suggests other stressors might also be risk
factors, under the general rubric of "maternal stress."
  As a result of such stresses, newborns of low birth
weight and short gestation have been linked to
increased risk of later developing schizophrenia (Jones
et al., 1998), as have delivery complications (Hultrnan
et al., 1997; Jones & Cannon, 1998) and other early
developmental problems (Brixey et al., 1993;
Ellenbroek & Cools, 1998; Portin & Alanen, 1998;
Preti et al., 1998). Among children, especially infants,
viral central nervous system infections may be
associated with greater risk (Rantakallio et al., 1997;
Iwahashi et al., 1998), thereby explaining links between
schizophrenia and being born or raised in crowded
conditions (Torrey & Yolken, 1998) or during the flu-
prone winter and spring months (Castrogiovanni et al.,
1998). However, support for these hypotheses is
inconsistent and incomplete (Yolken & Torrey, 1995).
In fact, it is possible that prenatal and obstetric
complications associated with schizophrenia could
reflect already disrupted fetal development, rather than
being causal themselves (Lipska& Weinberger, 1997).
More generally, across the life span, the chronic
stresses of poverty (Cohen, 1993; Saraceno & Barbui,
,1997) and some facets of minority social status appear
to alter the course of schizophrenia.

Presently, it is unclear whether and how these risks
contribute to the diathesis-stress interaction for any one
person because specific causes may differ (Onstad et
al., 1991; Cardno & Farmer, 1995; Tsuang & Faraone,
1995; Miller, 1996). Although genetic vulnerability is
difficult to control, certain other important factors can
be addressed with current knowledge. An awareness of
stressors that increase the likelihood of genetic
vulnerability being actualized supports preventive
strategies, such as good prenatal health care and
nutrition. Furthermore,  since life stresses can
exacerbate the course of the ill&s, access to good
quality services and social supports, as well as attention
to relapse prevention interventions, can have beneficial
effects on longer term outcome (Wiersma et al., 1998).
  At the same time, researchers and clinicians are
striving to integrate findings concerning both diathesis
and stress into models of how schizophrenia develops
(Andreasen, 1997b). Not only does brain biology
influence behavior and experience, but behavior and
experience mold brain biology as well. One promising
integrative model is the neurodevelopmental theory of
schizophrenia developed by Weinberger and others
(Murray & Lewis, 1987; Weinberger, 1987, 1995;
Bloom, 1993; Weinberger & Lipska, 1995; Lipska &
Weinberger, 1997). It posits that schizophrenia
develops from "a subtle defect in cerebral development
that disrupts late-maturing, highly evolved neocortical
functions, and fully manifests itself years later in adult
life" (Lip&a & Weinberger, 1997; see also Susser et
al., 1998).

The nature of the defect, which has not been
identified, may be a product of a pre- or neonatal insult
to the brain. Further support for the neuro-
developmental theory comes from abnormalities in
brain structure that have long been found in people
with schizophrenia.  Such findings have been
interpreted to reflect abnormal neuronal migration in
early development (Jakob & Beckmann, 1986; Arnold
et al., 1991; Akbarian et al., 1993; Falkai et al., 1995).
Researchers have developed animal models of early
neurodevelopmental dysfunctions that manifest in later
behavioral and functional deficits (Geyer et al., 1993;
Lipska & Weinberger, 1993; Wilkinson et al., 1994;

278


Adults and Mental Health

Table 4-8. Selected treatment recommendations, Schizophrenia Patient Outcomes Research Team

t

bcommendation 1. Antipsychotic medications, other than clozapine, should be used as the first-line treatment to reduce
)sychotic symptoms for persons experiencing an acute symptom episode of schizophrenia.

3ecommendation 2. The dosage of antipsychotic medication for an acute symptom episode should be in the range of
300-l ,000 chlorpromazine (CPZ) equivalents per day for a minimum of 6 weeks. Reasons for dosages outside this range
should be justified. The minimum effective dose should be used.

?ecommendation 8.` Persons who experience acute symptom relief with an antipsychotic medication should continue to
,eceive this medication for at least 1 year subsequent to symptom stabilization to reduce the risk of relapse or worsening
)f positive symptoms.

3ecommendation 9. The maintenance dosage of antipsychotic medication should be in the range of 300-600 CPZ
equivalents (oral or depot) per day.

Recommendation 12. Depot antipsychotic maintenance therapy should be strongly considered for persons who have
difficulty complying with oral medication or who prefer the depot regimen.

Recommendation 23. Individual and group therapies employing well-specified combinations of support, education, and
Dehavioral and cognitive skills training approaches designed to address the specific deficits of persons with schizophrenia
should be offered over time to improve functioning and enhance other target problems, such as medication
noncompliance.

Recommendation 24. Patients who have ongoing contact with their families should be offered a family psychosocial
intervention that spans at least 9 months and that provides a combination of education about the illness, family support,
crisis intervention, and problem-solving skills training. Such interventions should also be offered to nonfamily members.

Recommendation 27. Selected persons with schizophrenia should be offered vocational services.*

Recommendation 29. Systems of care serving persons with schizophrenia who are high users should include ACT and
ACM programs.

o Edited

Source: Lehman & Steinwachs, 1998a, 1998b.

Lipskaet al., 1995) and are influenced by genetics (de
Kloet et al., 1996; Zaharia et al., 1996). As promising
as these theories are, the causes and mechanisms of
schizophrenia remain unknown. Nonetheless, research
has uncovered several types of treatment for
schizophrenia that are effective in reducing symptoms
and functional impairments.

Interventions

The treatment of schizophrenia has advanced
considerably in recent years. A battery of treatments
has become available to ameliorate symptoms, to
improve quality of life, and to restore productive lives.

Treatment and other service interventions often are
linked to the clinical phases of schizophrenia: acute
phase, stabilizing phase, stable (or maintenance) phase,
and recovery phase. Where possible, this report ties
available data to these treatment phases.

Optimal treatment across all phases of treatment
includes some form of pharmacotherapy with
antipsychotic medication, usually combined with a
variety of psychosocial interventions. Psychosocial
interventions include supportive psychotherapy, and
family psychoeducational interventions, as well as
psychosocial and vocational rehabilitation. The
treatment of individuals with schizophrenia who are

279


Mental Health: A Report of the Surgeon General

high service users should be orchestrated by an
interdisciplinary treatment team to ensure continuity of
services (i.e., assertive community treatment, which is
discussed below). Others may benefit from less
intensive forms of case management and various self-
help and consumer-operated services, described later.
It is also important to assist individuals with schizo-
phrenia in meeting their many related needs, such as for
supported housing, transportation, and general medical
care. These are among the 30 pivotal treatment
recommendations of the Agency for Health Care Policy
and Research- and NIMH-sponsored Schizophrenia
Patient Outcomes Research Team (PORT), which
developed its recommendations on the basis of a
comprehensive review of the treatment outcomes
literature (Lehman & Steinwachs, 1998a). Table 4-8
contains a distillation of key recommendations.
  Although  the Schizophrenia PORT study
recommendations are grounded in research such as that
reviewed in the following paragraphs, it is noteworthy
that treatment practices fail to adhere to these
recommendations, with conformance generally falling
below 50 percent (Lehman & Steinwachs, 1998b). The
disturbing gap between knowledge and practice is
discussed later in this chapter. Many barriers. exist in
the transfer of information about treatment. and
evidence-based practice to clinicians, family members,
and service users.

fbarmacotherapy

Pharmacotherapies are the most extensively evaluated
intervention for schizophrenia. The conventional or
older antipsychotic medications (e.g., chlorpromazine,
haloperidol, fluphenazine, molindone) and the more
recently developed medications (e.g., clozapine,
risperidone, olanzapine, quetiapine, sertindole) are used
to reduce the positive symptoms of schizophrenia. The
newer medications, often called atypical because they
have a different mechanism action than their
predecessors, also appear in preliminary studies to be
more effective against negative symptoms, display
fewer side effects, and show promise for treating
people for whom older medications are ineffective
(Ballus, 1997). Their introduction has created more

treatment options for people with schizophrenia and
other serious mental illnesses. Although the newer,
more broadly effective medications have increased
hopes for recovery, they also have resulted in greater
treatment complexity for patients and providers alike
(Fenton & Kane, 1997).

Conventional antipsychotics have been shown to be
highly effective both in treating acute symptom
episodes and in long-term maintenance and prevention
of relapse (Cole & Davis, 1969; Davis et al., 1989;
Kane, 1992). Across many studies, positive symptoms
improved in about 70 percent of patients, compared
with only 25 percent improvement in placebo groups
(Kane, 1989; Kane & Marder, 1993). Their common
mechanism of action is by blocking dopamine D,
receptors, and their therapeutic effects are presumably
due to D, blockade in the mesolimbic system (Dixon et
al., 1995).

For acute symptom episodes, treatment recom-
mendations call for dosages of antipsychotic
medication in the range of 300 to 1,000
"chlor@omazine equivalents"14 per day (Lehman &
Steinwachs, 1998b). Among patients discharged from
inpatient units whose dosage fell outside of this range,
minority patients often are much more likely than
Caucasian patients to be on a higher dose (> 1,000
chlorpromazine equivalents) (Lehman & Steinwachs,
1998b). Such dosing patterns run counter to evidence
that a higher proportion of minority patients, because of
lower rates of drug metabolism, may require lower
doses of antipsychotics.

Dosage studies have found that moderate levels
(300 to 750 chlorpromazine equivalents daily for acute
episodes, 300 to 600 for maintenance, although many
people require less than 300) are more effective for
positive symptom reduction over the long run than very
high ("loading"), intermittent, or very low doses
(Donlon et al., 1978, 1980; Neborsky et al., 1981;
Baldessarini et al., 1990; Levinson et al., 1990; Van
Putten et al., 1990,1992; Rifkin et al., 1991). Very low

I4

A chlorpromazine equivalent is a measure in milligrams
of antipsychotic medication doses indexed to the potency of
a standard dosage of chlorpromazine, one of the earliest, most
widely used antipsychotic medications.

280


and intermittent dosing substantially increases the risk
of relapse, while rapid loading and very high doses
greatly increase adverse effects (Davis et al., 1989),
although medication programs must be tailored to
individual needs. On conventional neuroleptics,
patients experience symptom reduction over the first 5
to 10 weeks of treatment, with more gradual
improvement sometimes continuing for more than
double that time (Baldessarini et al., 1990). The older
medications are occasionally found to reduce some
negative symptoms as well, although it is impossible to
tell from existing research if this is a primary or
secondary effect of reduced positive symptoms (Davis
et al., 1989; Cassens et al., 1990).
Apart from their minimal effects on negative
symptoms, the greatest problem with conventional
neuroleptic  medications  is their pervasive,
uncomfortable, and sometimes disabling and dangerous
side effects. The spectrum of side effects is broad
(Davis et al., 1989; Casey, 1997), yet the most common
and troubling are extrapyramidal effects such as acute
dystonia, parkinsonism, and tardive dyskinesia (Chakos
et al., 1996; Yuen et al., 1996; Trugman, 1998)
andakathisia (Kane, 1985).15 Side effects are evident in
an estimated 40 percent of patients, but .pinpointing
their prevalence is complicated by the vagaries of
diagnosis, length of prescription and observation, and
variability across individuals and medications. Rare
side effects (seizures, paradoxical exacerbation of
psychotic symptoms, neuroleptic malignant syndrome)
also can be devastating.

Acute dystonia, parkinsonism, dyskinesias, and
akathisia are usually treated by lowering the doses of
neuroleptics and/or using adjunctive anticholinergic,
antiparkinsonian medications (e.g., benztropine).
Because these side effects can be mistaken for core
psychotic symptoms, the neuroleptic dose is often
increased, rather than decreased, exacerbating the side

I5

Acute dystonia is involuntary muscle spasms resulting in
abnormal and usually painful body positions. Parkinsonism
is defined by tremors, muscle rigidity, and stuporous appearance.
Dyskinesias are involuntary repetitive movements, often of the
mouth, face, or hands, and akathisia is painful muscular restless-
ness requiring the person to move constantly.

Adults and Mental Health

effects. Many other side effects such as attention and
vigilance problems, sleepiness, blurry vision, dry
mouth, and constipation are worse in the initial weeks
of treatment and usually taper off as a person adjusts to
the medication. However, the discomfort and disability
of the initial weeks are intolerably disruptive to some
individuals. Dosages can be individualized to minimize
side effects while maximizing benefit.
Efficacy data on the newer antipsychotics indicate
that they are as efficacious as the older agents at
reducing positive symptoms and carry fewer side
effects. They also offer important additional advantages
for some who have had treatment-resistant
schizophrenia (Kane, 1996, 1997; Vanelle, 1997; van
OS et al., 1997; Andersson et al., 1998).
  The prototype of the newer medications,
clozapine, has been found effective for about 30 to 50
percent of treatment-resistant patients (Kane & Marder,
1993; Lieberman et al., 1994; Buchanan, 1995; Kane &
McGlashan, 1995; Kane, 1996), as well as for patients
who have responded to previous medications.
Clozapine also seems to help secondary depression and
anxiety, and perhaps the negative symptoms of
schizophrenia (Buchanan, 1995). Clozapine not only
has a very low incidence of tardive dyskinesia (Barnes
& McPhillips, 1998) but may also show some promise
as its treatment (Walters et al., 1997). However, the use
of clozapine was constrained for many years in the
United States because of findings that in about 1
percent of patients it causes a potentially fatal blood
condition: agranulocytosis, a loss of white blood cells
that fight infection. Because agranulocytosis is
reversible if detected early, frequent (weekly) blood
monitoring is critical (Lamarque, 1996; Meltzer, 1997).
Although effective safeguards exist, use of clozapine
tends to be limited to those who are unresponsive to, or
cannot tolerate, other antipsychotics. The Veterans'
Administration sponsored the largest cost-effectiveness
study to date of clozapine, comparing it to haloperidol.
Studies by Rosenheck and his collaborators (1997,
1998b, 1999) replicated previous findings that
clozapine was more effective than haloperidol in
treating positive and negative symptoms and had fewer
extrapyramidal side effects. In addition to its direct

281


Mental Health: A Report of the Surgeon General

pharmacologic effect, the investigators found that
clozapine enhances participation in psychosocial
treatments, which augments its overall clinical
effectiveness (Rosenheck et al., 1998b). Savings
associated with use of clozapine were particularly
significant among study participants who had averaged
2 15 inpatient hospital days in the year prior to the study
(Rosenheck et al., 19981;).

Increasing numbers of patients with schizophrenia
receive newer agents like risperidone (Smith et al.,
1996a; Foster & Goa, 1998), olanzapine (Bymaster et
al., 1997), and quetiapine (Wetzel et al., 1995;
Gunasekara & Spencer, 1998). They have replaced the
older antipsychotics in many cases because they cause
fewer side effects at therapeutic levels (Umbricht &
Kane, 1995) and do not require clozapine's close
monitoring. Their effects on negative schizophrenia
symptoms are currently being evahtated and hold some
promise, as do their effects on some cognitive
dysfunctions (Gallhofer et al., 1996; Green et al., 1997;
Kern et al., 1998). Furthermore, current cost analyses
find these newer medications at least cost-neutral and
sometimes more cost-effective in the long run than
older agents, despite being more expensive per pill
(Loebel et al., 1998).

  Thus, as a whole, there is evidence that the newer
antipsychotics are more clinically advantageous than
the older ones due to the combination of their effective
treatment of positive (and perhaps negative) symptoms,
their treatment of ancillary symptoms such as anxiety
and depression, and their more favorable side effect
profile (Liebetman, 1993, 1996; Fleischhacker &
Hummer, 1997; Shore, 1998). Having fewer side
effects generally results in better compliance with the
medication, although atypical side effects can include
sedation, weight gain, sexual dysfunction, and other
dose-related discomforts (Casey, 1997; Hasan &
Buckley, 1998). Although the newer agents have less
adverse impact on fecundity, so that more women with
schizophrenia can conceive, there are very little data to
address the impact of treatment on pregnancy and
lactation. While it is not clear whether the newer
medications directly lessen the functional disabilities
that usually accompany schizophrenia, they may

Growing awareness that ethnicity and culture influence
patients' response to medications has catapulted to
prominence the field of ethnopharmacology. In the past
decade, studies have demonstrated that psychiatric
medications interact with patient ethnicity in multiple
ways, with response to the same medication and dose
varying by patient ethnicity (Frackiewicz et al., 1997).
For example, due to racial and ethnic variation in
pharmacokinetics,  Asians and Hispanics with
schizophrenia may require lower doses of
antipsychotics than Caucasians to achieve the same
blood levels (Collazo et al., 1996; Ramirez, 1996; Ruiz
et al., 1996). Pharmacokinetics and pharrnacodynamics
also vary across other ethnic group~.`~ Racial and
ethnic variation likely stem from a combination of
genetic and psychosocial factors, such as diet and
health behaviors (Lin et al., 1995).

282

At the same time, it is possible that the documented
medication differences are the result of underlying
biological mechanisms of mental illness related to
ethnicity, culture, and gender variations. Additionally,
the effects of psychotropic medications may be
interpreted differently by culture (Lewis et al., 1980).
Although knowledge in these areas is incomplete, it is
important to consider cultural patterns in dosing
decisions and medication management, as well as risks
of side effects and tardive dyskinesia. Furthermore,
studies suggest that medication differences among
African American people diagnosed with schizophrenia
may reflect clinician biases in diagnosis and
prescription practices more than differences in

I6 For Caucasian, Hispanic, Asian, Africian-Americans varia-
tions, see Frackiewicz et al., 1997; Chinese-Jam et al., 1992;
black, white, Chinese, Mexican American-Lam et al., 1995;
Lin et al., 1995).

improve a person's quality of life (Lehman, 1996) and
responsiveness to psychosocial, rehabilitation, and
therapeutic  interventions  (Buckley, 1997).
Effectiveness in real-world settings may be
substantially lower than efficacy in clinical trials,
possibly due to patient heterogeneity, prescribing
practices, and noncompliance (Dixon et al., 1995).

f ttmopsychopharmaco/ogy


medication metabolism or health behaviors alone
(Frackiewicz et al., 1997).

psychosocial Treatments

Psychosocial treatments are vital complements to
medication for individuals with schizophrenia. They
help patients maximize functioning and recovery. The
PORT treatment recommendations, as noted earlier,
stipulate that patients should receive pharmacotherapy
in conjunction with supportive psychotherapy, family
treatment, psychosocial rehabilitation and skill
development, and vocational rehabilitation (Lehman &
Steinwachs, 1998a). In the active phase of illness,
medication enables patients to be more receptive to
psychosocial treatments. During periods of remission,
when maintenance medication is still recommended,
psychosocial treatments continue to help patients to
improve quality of life. Psychosocial treatments assume
even greater importance for patients who do not
respond to,  cannot tolerate, or refuse to take
medications.  Several decades ago, psychosocial
programs were developed that used little or no
medication (Mosher, 1999). For a highly selected group
of patients at the beginning of their first acute episode
of schizophrenia, these programs were reported
effective (Mosher & Menn, 1978). Most patients,
however, do not meet the selection criteria employed in
this study. Few such programs are currently operating
(Mosher, 1999), and treatment with antipsychotic
medication is recommended in conjunction with
psychosocial treatments (Lehman & Steinwachs,
1998a).

Psychotherapy

Outcomes of individual and group therapies have been
studied for people with schizophrenia, although not
extensively and not in relation to current managed care
practices. Overall, it is clear that individual and group
therapies that focus on practical life problems
associated with schizophrenia (e.g., life skills training)
are superior to psychodynamically oriented therapies
(Scott & Dixon, 1995a). Psychodynamically oriented
therapies are considered to be potentially harmful;
therefore, their use is not recommended (Lehman,

Adults and Mental Health

1997). Individual, group, or famiiy therapies that
combine support, education, and behavioral and
cognitive skills, and that address specific challenges,
can help clients cope with their illness and improve
their functioning, quality of life, and degree of social
integration. However, the optimum length of therapy
seems to be longer than that afforded by "brief therapy"
(Gunderson et al., 1984; Stanton et al., 1984; Hogarty
et al., 1997). Additionally, certain targeted therapeutic
interventions may be useful in addressing specific
symptoms (Drury et al., 1996; Jensen & Kane, 1996).
Certain subgroups of clients- appear to find different
types of therapy more or less useful than others (Scott
& Dixon, 1995a).

Family Interventions

Several professionally operated family intervention
programs have been developed to help the family
member with severe mental illness (e.g., Hogarty et al.,
1987; Cazzullo et al., 1989; Mari & Streiner, 1994;
McFarlane, 1997). Randomized trials have been
conducted for interventions that educate families about
schizophrenia, provide support and crisis intervention,
and offer training in effective problem solving and
communication. These interventions have strongly and
consistently demonstrated their value in preventing or
delaying symptom relapse and appear to improve the
patient's overall functioning and family well-being
(Goldstein et al., 1978; Falloon et al., 1985; Strachan,
1986; Lam, 1991; Tarrier et al., 1994; Goldstein 1995a;
Penn & Mueser, 1996). Research has suggested that
groups of multiple families are more effective and less
expensive than individual family interventions
(McFarlane et al., 1995). Incorporating family religious
and ethnic background may prove useful in family
interventions (Guamaccia et al., 1992). Family self-
help groups are discussed subsequently in this chapter.

Psychosocial Rehabilitation and Skills Development
Psychosocial skills training strives to teach clients
verbal and nonverbal interpersonal skills and
competencies to live successfully in community
settings. Skills or tasks are divided into small, simple
behavioral elements that the client then learns,

283


Mental Health: A Report of the Surgeon General

practices, and puts together. Currently, there is a
growing addition of cognitive skill remediation to
rehabilitation programs that have focused on social
skills training (Bellack et al., 1989; Bellack & Mueser,
1993; Scott & Dixon, 1995a). As one example of the
scope of such programs, the program examined by
Liberman and co-workers (1998) focused on four skill
areas: medication management, symptommanagement,
recreation for leisure, and basic conversation skills.
Each area was addressed through concrete topics, with
the basic conversation skills module, for example,
consisting of active listening skills, initiating
conversations, maintaining conversations, terminating
conversations, and putting it all together.
The evolution of psychosocial skills training is
important yet incomplete. A review in the mid-1990s
concluded that its overall impact on social, cognitive,
or vocational functioning is modest, and it remains
unclear whether these gains are maintained after the
training is over and can be used in real-life situations
(Scott & Dixon, 1995a). However, a more recent study
found greater independent living skills among clients
who had received skills training during a 2-year
followup of everyday community functioning
(Liberman et al., 1998). Several others agree that skills
training is effective for specific behavioral outcomes
(Marder et al., 1996; Penn & Mueser, 1996). Specific
symptom profiles may also influence how effective
skills training is for a given person (Kopelowicz et al.,
1997). Furthermore, Medalia and coworkers (1998)
report recent success adapting cognitive rehabilitation
techniques, originally developed for survivors of
serious head injuries, for people with schizophrenia,
but long-term effects and generalizability have not been
determined. This exemplifies both the progress and the
need for further refinement of this intervention (Smith
et al., 1996b).

284

In a recent review article, a team of researchers
concluded that the most potent rehabilitation programs
(1) establish direct, behavioral goals; (2) are oriented to
specific effects on related outcomes; (3) focus on long-
term interventions; (4) occur within or close to clients'
naturally preferred settings; and (5) combine skills
training with an array of social and environmental

supports. They also note that most programs do not
contain all of these elements, but most are much
improved over previous eras (Mueser et al., 1997b).
There are a host of multi-component psychosocial
rehabilitation services that combine pharmacologic
treatment, independent living and social skills training,
psychological support to clients and their families,
housing, vocational rehabilitation, social support and
network enhancement, and access to leisure activities
(World Health Organization [WHO], 1997). These are
discussed in the later section on service delivery.

Coping and Self-Monitoring

An important goal of recovery and the consumer
movement is to enable patients themselves to
participate more actively in their own treatment. While
complete remission of all symptoms is unlikely for the
majority, most can and do learn skills and techniques
over time that they can use to manage distressing
symptoms and the effects of the illness. Often, better
skills in coping and monitoring one's own health status
occurs simply through experience. However, the
growth of self-help and the development of recovery
models for serious mental illnesses has spawned
interventions that purposefully teach and encourage
active coping on the part of clients and their families.
Controlled research is sparse (Penn & Mueser, 1996),
except in the area of relapse prevention.

For example, some people find it very useful to pay
attention to their own warning signs of relapse or
symptom exacerbation, so that additional coping
practices, supports, or interventions can be put into
place. Norman and Malla (1995) conclude that there is
not a standardized set of signs that predict relapse, but
that some individuals have and get to know their own
reasonably consistent patterns. Herz and Lamberti
(1995) agree that many people experience predictable
signs, although whether a relapse occnrs depends on
many factors besides the signs themselves. Therefore,
the risk and magnitude of relapse can be reduced by
monitoring early symptoms and intervening when they
emerge (Herz & Larnberti, 1995). Watching for such
signs is recommended for consumers, family members,
and clinicians (Jorgensen, 1998). Specific training


programs for teaching individuals with schizophrenia
to identify the warning signs of relapse and to develop
relapse prevention plans have been shown to be
effective (Liberman et al., 1998).

Vocational Rehabilitation

Unemployment is pervasive among people with serious
and persistent mental illness. Employment is valued
highly by the general public and by people with
schizophrenia alike because it generates financial
independence, social status, contact with other people,
structured time and goals, and opportunities for
personal achievement and community contribution
(Mowbray et al.,  1997). These attributes of
employment, combined with the self-esteem and
personal purpose that it engenders, make vocational
rehabilitation a prominent facet of treatment for serious
mental illnesses. Vocational rehabilitation is especially
important because early adult onset often disrupts
education and employment history.
  Controlled studies of vocational rehabilitation
interventions have shown mixed results (Lehman, 1995,
1998; Cook & Jonikas, 1996). Although such programs
do seem to increase work-related activities while
people are engaged in them, the gains do not seem to be
translated into more independent employment once
services cease. This has led to the conclusion that
ongoing support is needed for many individuals with
schizophrenia who wish to work in competitive
employment (Wehman, 1988). Recent controlled
studies have shown the effectiveness of this newer type
of so-called supported employment models, which
emphasize rapid placement in a real job setting and
strong support from a job coach to learn, adapt, and
maintain the position (Drake et al., 1994, 1996; Bond
et al., 1997). These models, which are growing in use,
strike a dynamic balance between being supportive yet
challenging in order to avoid clients' dependency and
maximize their growth (Mowbray et al., 1997).

As vocational rehabilitation has moved away from
sheltered workshops and toward supported employment
models, the Americans With Disabilities Act of 1990
has helped to open jobs and educate employers about
reasonable accommodations for people with psychiatric

Adults and Mental Health

disabilities (Mechanic, 1998; Scheid, 1998).
Additionally, innovations like client-run and client-
owned vocational programs and independent businesses
have begun to be developed on a larger scale (Rowland
et al., 1993; Miller & Miller, 1997). These innovations
are part of a larger movement of consumer involvement
in the provision of services for people with mental
illness (see Chapter 2).

Service Delivery

The organization of services for adults with severe
mental disorders is the linchpi#n of effective treatment.
Since many mental disorders are best treated by a
constellation of medical and psychosocial services, it is
not just the services in isolation, but the delivery
system as a whole, that dictates the outcome of
treatment (Goldman, 1998b). Access to a delivery
system is critical for individuals with severe mental
illness not only for treatment of symptoms but also to
achieve a measure of community participation.
Among the fundamental elements of effective
service delivery are integrated community-based
services, continuity of providers and treatments, and
culturally sensitive and high-quality, empowering
services (Mowbray et al., 1997; Lehman & Steinwachs,
1998a). Effective service delivery also requires support
from the social welfare system in the form of housing,
job opportunities, welfare, and transportation
(Goldman, 1998a), issues that are discussed in the final
section of this chapter.

What models of service delivery are most
effective? This section strives to answer this question
by focusing on models of service delivery for
individuals with severe and persistent mental disorders,
including severe depression and bipolar disorder, as
well as schizophrenia. Although adults with mental
illness in midlife confront many service delivery
issues-for example,  the problem of proper
identification and treatment of depression in primary
care settings-those who are most disabled by mental
disorders encounter special service delivery problems.
The focus on the most disabled is warranted for three
reasons: (1) Society has a special obligation to those
who are most impaired and consequently are the "least

285


Mental Health: A Report of the Surgeon General

well off' (Callahan, 1999; Goldman, 1999; Rosenheck,
1999); (2) the body of research on mental health
services delivery for this population is extensive; and
(3) existing service systems are seriously deficient.
The deficiency of existing service systems is best
documented for individuals with schizophrenia. The
majority of people with schizophrenia do not receive
the treatment and support they need, according to a
groundbreaking finding of PORT (Lehman &
Steinwachs, 1998a). PORT, as noted earlier, developed
a series of basic treatment recommendations after
reviewing hundreds of outcome studies. It proceeded to
determine whether these recommendations were being
met by examining current patterns of care in two states
in the United States.
Among those with severe mental disorders, any
number of special populations might have been the
focus for this section. These special populations have
severe mental disorders and HIV/AIDS (Coumos &
McKinnon, 1997); are involved in the criminal justice
system(Abram& Teplin, 1991; CMHS, 1995;Lamb &
Weinberger, 1998); or have somatic health problems
(Berren et al., 1994; Felker et al., 1996; Brown, 1997).
Although some of what follows may be relevant to the
unique needs of each of these groups, the evidence base
is less well developed.

  The remainder of this section focuses on case
management,  assertive community treatment,
psychosocial  rehabilitation services,  inpatient
hospitalization and community alternatives for crisis
care, and combined treatment for people with the dual
diagnosis of substance abuse and severe mental illness.

Case Management

The purpose of case management is to coordinate
service delivery and to ensure continuity and
integration of services. Case managers engage in a
variety of activities, ranging from simple roles in
locating  services to more intensive roles in
rehabilitation and clinical care. The less intensive
models of case management seem to increase clients'
links to, and use of, other mental health services at
relatively modest cost. More intensive models also
appear to help clients to increase daily-task functioning,

residential stability, and independence, and to reduce
their hospitalizations (Borland et al., 1989; Mueser et
al., 1998a). Overall, models that focus on specific
outcomes are more effective than those with global,
vaguely defined goals (Attkisson et al., 1992).
More programs are beginning to employ mental
health consumers as case managers in their
multidisciplinary staff. Results have been positive, but
the programs are challenging to implement and require
ongoing supervision as do all case management
programs (Mowbray et al., 1996). In a controlled study,
clients served by case management'teams, along with
consumers as peer-specialists, displayed greater gains
in several areas of quality of life and greater reductions
in major life problems, as compared with two
comparison groups of clients served by case
management teams without peer-specialists (Felton et
al., 1995). One randomized clinical trial compared case
management teams wholly staffed by consumers versus
case management teams staffed by nonconsumers. The
study (at 1 -year and 2-year followup) found that clients
improved equally well with consumer  and
nonconsumer case managers (Solomon & Draine,
1995). In this series of studies, the case management
teams were part of an intensive program of services
known as assertive community treatment.

Assertive Community Treatment
Assertive community treatment is an intensive
approach to the treatment of people with serious mental
illnesses that relies on provision of a comprehensive
array of services in the community. The model
originated in the late 1970s with the Program of
Assertive Community Treatment in Madison,
Wisconsin (Stein & Test, 1980). Fueled by
deinstitutionalization and the vital need for cornmunity-
based services, a multidisciplinary team serving
psychiatric inpatients adapted its role to patients in the
community. For this reason, assertive community
treatment often is likened to a "hospital without walls."

The hallmark of assertive community treatment is
an interdisciplinary team of usually 10 to 12
professionals, including case managers, a psychiatrist,
several nurses  and  social workers,  vocational

286


specialists, and more recently includes substance abuse
treatment specialists and peer specialists. Assertive
community treatment also possesses these features:
coverage 24 hours, 7 days per week; comprehensive
treatment planning; ongoing responsibility; staff
continuity; and small caseloads, most commonly with
1 staff member for every 10 clients (Scott & Dixon,
1995b). Because of the intensity of services, assertive
community treatment is most cost-effective when
targeted to individuals with the greatest service need,
particularly those  with a history of multiple
hospitalizations (Scott & Dixon, 1995b; Lehman &
Steinwachs et al., 1998a).

  Randomized controlled trials have demonstrated
that assertive comtintnity treatment and similar models
of intensive case management substantially reduce
inpatient service use, promote continuity of outpatient
care, and increase community tenure and residence
stability for people with serious mental illnesses (Stein
& Test, 1980; Bond et al., 1995; Lehman, 1998;
Mueser et al., 1998a). Among the beneficiaries are
homeless individuals and those with substance abuse
problems  and mental disorders. Evidence of
effectiveness is weaker for other outcomes (e.g., social
integration, employment) and for amelioration of
substance abuse problems associated with
schizophrenia, particularly when combined treatment is
not offered (Mueser et al., 1998b). Assertive
community treatment models are generally popular
with clients (Stein & Test, 1980) and family members
(Flynn, 1998). There also are some preliminary results
suggesting that employing peer (i.e., consumer) or
family outreach workers on the multidisciplinary
assertive community treatment teams increases positive
outcomes (Dixon et a1.,1997, 1998) and creates more
positive attitudes among team members toward people
with mental illnesses.

Psychosocial Rehabilitation Services
As noted above, there are a range of multicomponent
programs called psychosocial rehabilitation services
that are distinct from the single component skills
training interventions described in the section on
interventions for schizophrenia. These psychosocial

Adults and Mental Health

rehabilitation programs  combine pharmacologic
treatment, independent living and social skills training,
psychological support to clients and their families,
housing, vocational rehabilitation, social support and
network enhancement, and access to leisure activities
(WHO, 1997). Randomized clinical trials have shown
that psychosocial rehabilitation recipients experience
fewer and shorter hospitalizations than comparison
groups in traditional outpatient treatment (Dincin &
Witheridge, 1982; Bell & Ryan, 1984). In addition,
recipients are more likely to be employed (Bond &
Dincin, 1986). Cook & Jon&as (1996) review the
outcomes of a wide range of psychosocial rehabilitation
programs, including Fairweather lodges (Fairweather et
al., 1969) and psychosocial clubhouses (Dincin, 1975),
some of which were demonstrated as effective 20 and
30 years ago but have not been widely implemented.

Inpatient Hospitalization and Community
Alternatives for Crisis Care
The role of psychiatric hospitalization has changed
greatly over recent decades, stemming from the
recognition of poor  and occasionally abusive
conditions, excessive patient dependency, and patients'
loss of connection to the community (Wing, 1962;
Gruenberg,  1974). More recent evolution in
hospitalization traces to changes in the financing of
care and the introduction of new medications (Appleby
et al., 1993; Bezold et al., 1996). Community-based
alternatives for crisis care services began to flourish in
lieu of hospitalization (Fenton et al., 1998; Mosher,
1999).

The new priorities of psychiatric hospitalization
focus on ameliorating the risk of danger to self or
others in those circumstances in which dangerous
behavior is associated with mental disorder, and the
rapid return of patients to the community (Sederer &
Dickey, 1995). Inpatient units are seen as short-term
intensive settings to contain and resolve crises that
cannot be resolved in the community. For this reason,
inpatients are commonly suicidal, homicidal, or
decompensating (experiencing the rapid return of
severe symptoms) to the degree that they cannot care
for themselves or respond to community-based

287


Mental Health: A Report of the Surgeon General

services. Inpatient services therefore emphasize safety
measures, crisis intervention, acute medication and re-
evaluation of ongoing medications, and (re)establishing
the client's links to other supports and services
(Sederer & Dickey, 1997).

Mobile crisis services have developed in many
urban areas to prevent hospitalization (Zealberg, 1997),
as have day hospital programs. With crisis services, a
multidisciplinary team comes directly to the aid of the
client in the community to provide immediate
evaluation and services. This new conceptualization of
inpatient care and crisis intervention services
minimizes the use of hospital resources; however, welI-
coordinated teams, sufficient community programs, and
ready linkages are not widely available, particularly in
rural and frontier areas.

  African Americans and Native Americans are
overrepresented in psychiatric inpatient units in relation
to their representation in the population (Snowden &
Cheung, 1990; Snowden, in press). Overrepresentation
is found in hospitals of all types except private
psychiatric hospitals. The reasons for this disparity,
while not completely understood, may reflect a mix of
limited access to outpatient services and differences in
cultural patterns of help-seeking behavior and overt
discriminatory practices. Cost, disinclination to seek
help, and lack of community support may contribute to
patients' delay in seeking treatment until symptoms are
severe enough to warrant inpatient care. Clinician bias
may also be at work. Cultural differences in treatment
seeking and treatment utilization are discussed in
greater detail in Chapter 2.

Services for Substance Abuse and Severe
Mental Illness
As many as hal'of people with serious mental illnesses
develop alcohol or other drug abuse problems at some
point in their lives (Mueser et al., 1990; Regier et al.,
1993, Drake & Osher, 1997). Theories to explain
comorbidity (also known as dual diagnosis) range from
genetic to psychosocial, but empirical support for any
one theory is inconclusive (Kosten & Ziedonis, 1997;
Mueser et al., 1998b). In short, the cause of such
widespread comorbidity is unknown.

Comorbidity worsens clinical course and outcomes
for individuals with mental disorders. It is associated
with symptom exacerbation, treatment noncompliance,
more frequent hospitalization, greater depression and
likelihood of suicide, incarceration, family friction, and
high services, use, and cost (Bartels et al., 1995;
Mueser et al., 1997a; Bellack& Gearon, 1998; Havassy
& Ams, 1998). Furthermore, patients may be
jeopardized by the consequences of substance abuse,
namely, increased risk of violence, HIV infection, and
alcohol-related disorders (IOM,,1995).
In light of the extent of mental disorder and
substance abuse comorbidity, substance abuse
treatment is a critical element of treatment for people
with mental disorders. Likewise, treatment of
symptoms and signs of mental disorders is a critical
element of recovery from substance abuse. Yet decades
of treating comorbidity through separate mental health
and substance abuse service systems proved ineffective
(Ridgely et al., 1990; Mueser et al., 1997a).
  Research amassed over the past 10 years supports
a shift to treatment that combines interventions directed
simultaneously to both conditions-that is, severe
mental illness and substance abuse-by the same group
of providers (Kosten & Ziedonis, 1997; for an
example, see Mowbray et al. 1995), but access to such
treatment remains limited. Most successful models of
combined treatment include case management, group
interventions (such as persuasion groups and social
skills training), and assertive outreach to bring people
into treatment (Mueser et al., 1997a). They typically
take into account the cognitive and motivational
deficits that characterize serious mental illnesses
(Bellack & Gearon, 1998), although many providers
still need to be educated (Kirchner et al., 1998).
Combined treatment is effective at engaging people
with both diagnoses in outpatient services, maintaining
continuity and consistency of care, reducing
hospitalization, and decreasing substance abuse, while
at the same time improving social functioning (Miner
et al., 1997; Mueser et al., 1997a).
  Although there is little evidence for any particular
approach to combining treatments for comorbidity (Ley
et al., 1999), recent research suggests that services

288


incorporating behavioral (motivational) approaches to
substance abuse treatment are superior to traditional
1Zstep approaches (e.g., Alcoholics Anonymous) with
this population of clients (Drake et al., 1998). This may
be because the more structured behavioral methods
better accommodate the cognitive difficulties that
accompany schizophrenia. Others, however, find self-
help interventions tailored to dual-diagnosis clients
quite useful (Vogel et al., 1998). Current research also
is seeking to tailor combined treatment to the needs and
preferences of specific patient subgroups, such as men,
women (Alexander, 1996), people with addiction to
multiple substances (as opposed to alcohol addiction
alone), and people with histories of physical and
psychological trauma (Mueser et al., 1997a).

Other Services And Stipports
Comprehensive care for adults with severe and
persistent mental disorders also includes ancillary
services to deal with such social consequences as
family disruption and loss of employment and housing.
Ancillary services are those above and beyond
symptom management and rehabilitation. They include
consumer self-help and advocacy, consumer-operated
programs, family self-help and advocacy, and human
services. The chapter concludes with a brief review of
. evidence about integrating the mental health service
system and the human services system of which it is
Pm*

A driving force for many of these services is to
redress the stigma associated with severe and persistent
mental illness. Stereotypes and ignorance are
omnipresent (Robert Wood Johnson Foundation, 1990;
Wahl et al., 1995). They lead many people to avoid
living, socializing, or working with, renting to, or
employing people with severe mental disorders (Levey
et al., 1995). Stigma reduces consumers' access to
resources and opportunities (e.g., housing, jobs), fuels
isolation and hopelessness, and leads to outright
discrimination and abuse. Thus, overcoming stigma
represents yet another challenge of coping with severe
and persistent mental illness and of working toward
recovery (Wahl & Harman, 1989; Reidy, 1993).

Adults and Mental Health

Consumer Self-Help

Self-help groups are geared for mutual support,
information, and growth. Self-help is based on the
premise that people with a shared condition who come
together can help themselves and each other to cope,
with the two-way interaction of giving and receiving
help considered advantageous. Self-help groups are
peer led rather than professionally led.
Organized self-help has a long history, with an
estimated 2 to 3 percent of the general population
involved in some self-help,group at any one time
(Borkman, 199 1,1997). Over the past several decades,
people with serious mental illnesses have formed
mutual assistance organizations to aid each other and to
combat stigma. These range from small groups held in
a member's home to freestanding nonprofit
organizations with paid staff and a range of programs.
In general, however, the self-help empowerment trend
does not appear to have reached the African-American,
Native American, HispaniclLatino, and Asian-
American populations.

As the number and variety of self-help groups has
grown, so too has social science research on their
benefits (Borkman, 1991). In general, participation in
self-help groups has been found to lessen feelings of
isolation, increase practical knowledge, and sustain
coping efforts (Powell, 1994; Kurtz, 1997). Similarly,
for people with schizophrenia or other mental
illnesses, participation in self-help groups increases
knowledge and enhances coping (Borkman, 1997;
Trainor et al., 1997). Various orientations include
replacing self-defeating thoughts and actions with
wellness-promoting activities  (Murray, 1996),
improved vocational involvement (Kaufmann, 1995),
social support and shared problem solving (Mowbray
& Tan, 1993), and crisis respite (Mead, 1997). Such
orientations are thought to contribute greatly to
increased coping, empowerment, and realistic hope for
the future. Additionally, some groups are tailored to
meet the needs of consumers who are members of
sexual minority groups, men, or those who have also
have substance disorders (Noordsy et al., 1996; Vogel
et al., 1998).

289


Mental Health: A Report of the Surgeon General

  A number of controlled studies have demonstrated
benefits for consumers participating in self-help. One
study of the self-help group Recovery, Inc., found that
leaders and members who were surveyed
retrospectively reported fewer symptoms and fewer
hospitalizations after joining the group than before. It
also found the leaders' reports of their psychological
well-being to have been comparable to community
controls (Galanter, 1988). In another study of 115
former mental patients, Luke (1989) found that those
who continued to attend self-help meetings at least
once per month over a period of 10 months were more
likely to show improvement on psychological,
interpersonal, or community adjustment measures than
those who attended less frequently. Through a case
study, which included focus groups and interviews,
Lieberman and colleagues (1991) found a consumer-
run support group to improve members' self-confidence
and self-esteem and to lead to fewer hospitalizations.
In a survey of mental health self-help group leaders
in New York State, respondents identified three
positive outcomes that were directly related to their
self-help group membership: greater self-esteem, more
hopefulness about the future, and a greater sense of
well-being. According to survey respondents,' all of
these positive changes led to fewer hospitalizations
(Carpinello & Knight, 1993). A study of six self-help
programs in several parts of the United States also
reported on consumers' perceptions of self-help
programs (Chamberlin & Rogers, 1990). Although not
nationally representative, consumers in this study
expressed satisfaction with their self-help program, at
which they spent an average of 15 hours per week.
They reported that their participation helped them to
solve problems and feel more in control of their lives.

Consumer-Operated Programs

Propelled by the growing consumer movement,
consumer self-help extends beyond self-help groups. It
also encompasses consumer-operated programs, such as
drop-in centers, case management programs, outreach
programs, businesses,  employment and housing
programs, and crisis services, among others (Long &
Van Tosh, 1988; National Resource Center on

Homelessness and Mental Illness, 1989; Van Tosh &
de1 Vecchio, in press). Drop-in centers are places for
obtaining social support and assistance with problems,
without professionals in attendance. The rationale for
cons,umer roles in service delivery is that consumer
staff, clients, and the mental health system can benefit.
Consumer staff are thought to gain meaningful work, to
serve as role models for clients, and to enhance the
sensitivity of the service system to the needs of people
with mental disorders. Clients are thought to gain from
being served by staff who are more,empathic and more
capable of engaging them in mental health services
(Mowbray et al., 1996).

An appreciation for the potential value of peer
support stimulated the Community Support Program of
the National Institute of Mental Health to fund local
consumer-operated Services Demonstration Projects
from 1988 to 1991. These demonstration projects also
resulted in the increasing involvement of mental health
consumers in the development and provision of peer
support, involvement in traditional service roles,
evaluation of services, and advocacy. A variety of
consumer-operated programs were developed, staffed,
and evaluated as states began to fund locally based
initiatives (Nikkel et al., 1992; Kaufmann et al., 1993;
Mowbray & Tan, 1993). Most evaluations of drop-in
centers were in the form of process evaluations that
generally found consumers to be satisfied or that
programs met their objectives (Kaufmann et al., 1993;
Mowbray & Tan, 1993). In 1998, the Federal Center
for Mental Health Services initiated a multisite
evaluation study of consumer-operated services across
the United States (see http://www.cstprogrum.edu).
In addition to ongoing evaluations, there are several
published studies of client outcomes withconsumer-run
programs, although the research base is modest. Several
studies, noted earlier, found improved outcomes with
consumer self-help programs. Another study evaluated
a consumer-run case management program. It compared
the effectiveness of a case management program staffed
by consumers with a similar program staffed by
nonconsumers. Case managers in both programs, which
were part of assertive community treatment, performed
brokering, assistance, and support functions, rather than

290


clinical management and treatment, The randomized
trial found that clients assigned to either case
management program fared equally well in clinical,
social, and quality of life outcomes (Solomon &
Draine, 1995). Recently, peer specialists were added to
the recommended staffing for assertive community
treatment teams; peer specialists provide expertise and
consultation to the entire treatment team (Allness &
Knoedler, 1999).

Consumers also may be employed as staff in more
traditional mental health services operated by
nonconsumer professionals. Consumer positions most
commonly include peer counselors, peer job coaches,
case managers, staff for drop-in centers, outreach
workers, and housing assistants. In a survey of 400
agencies offering supported housing to people with
severe mental illness, 38 percent employed mental
health consumers as paid staff (Besio & Mahler, 1993).
As noted previously, consumers in the role of peer-
specialists integrated into case management teams led
to improved patient outcomes (Felton et al., 1995).

Consumer Advocacy

The mental health field has witnessed great changes in
policy development,  with consumers playing
increasingly visible roles in advocacy. Consumer
contribution to policy was initially encouraged by
Federal laws mandating consumer participation in
planning, oversight, and advocacy activities at the state
level (Chamberlin & Rogers, 1990; Van Tosh & de1
Vecchio, in press). With the establishment of state
mental health planning councils and local mental health
advisory boards and committees, consumers
increasingly have become equal partners in a process
often reserved for seasoned policymakers. In addition,
consumers have become active participants in the
process to reform health and mental health care
financing. For example, the Managed Care Consortium
was formed in 1995 to create educational opportunities
for a host of advocacy organizations across the United
States. With funding support from the federal Center
for Mental Health Services, this consortium encouraged
teams to form in each state to influence the design of
managed care programs. Consumers also have entered

the halls of many public sector bureaucracies, serving
in leadership roles in Offices of Consumer Affairs and
interfacing withother government departments. In what
was once believed to be the last bastion for consumer
integration, consumers are now seen as critical
stakeholders and valued resources in the policy process.
  Consumers also have become advocates in the
communities where they live and work. Advocacy
enables consumer groups to shape policy at the local
level, where a direct impact can be felt. At the local
level, advocacy strives to improve access to, or quality
of, needed services and to saunter employment and
housing discrimination. It can also be helpful in
mobilizing resources to build and sustain programs.
The National Mental Health Association (NMHA.
available at http://www.nmha.org), comprising more
than 340 affiliates nationwide, works with and supports
the efforts of consumers to achieve advocacy goals.

291

Family Self-Help

Family members of people with severe mental illnesses
also encounter ignorance and stigma. Stigma translates
into avoiding or blaming family members (Phelan et al.,
1998; Wahl & Harman, 1989). Families also are under
a great deal of stress associated with care giving and
obtaining resources for their mentally ill members.
Families--especially parents, siblings, adult
children, and spouses--often provide housing, food,
transportation, encouragement, and practical assistance.
At the same time, schizophrenia and other mental
disorders strain family ties. Symptoms of mental
disorders may be disruptive and troubling, especially
when they flare up. Even when there are no problems,
living together can be stressful-interpersonally,
socially, and economically. Parents and their adult
children often perceive mental disorders and treatment
differently, sometimes disagreeing about the best
course of action.

Consequently, families too have created support
organizations. Some of these are professionally based
and facilitated, often as part of a clinic or other
treatment program. Others are peer run in the self-help
model. Similar to self-help among people with mental
illnesses, family self-help can range from small

Adults and Mental Health


Mental Health: A Report of the Surgeon General

supportive groups to large organizations. The National
Alliance for the Mentally Ill (NAMI) is the largest such
organization. Founded in 1979 in Wisconsin, NAM1
now has 208,000 members nationally. It has more than
1,200 local self-help groups (affiliates) across all 50
states (see http://www.nami.org). While still growing,
its members include only a small percentage of the
family members of people with mental illnesses in the
country (Monking, 1994; Heller et al., 1997a).
Family members primarily attend self-help and
support groups to receive emotional support and
accurate information about mental illness and mental
health services (Heller et al., 1997a, 1997b).
Participation often leads to better quality of life for the
attending family members and also indirectly benefits
the member diagnosed as mentally ill (Wahl & Harman,
1989; Monking, 1994). Family self-help groups can
result in better communication and interaction among
family members (Heller et al., 1997b).

Family Advocacy

In addition to providing each other with mutual
support, families often devote time, energy, and
resources for advocacy to improve services and
opportunities for their family members with mental
disorders. Similar to consumer advocacy,' family
advocacy on a local level might include organizing to
improve local mental health services, or to redress
grievances with service providers. On the national
level, consumer groups work to influence legislation
and to support research and education initiatives (Wahl
& Harman, 1989). Through their advocacy, families
have been quite effective in raising their concerns and
perspectives to service providers, legislators, and the
public.

Human Services

The clinical symptoms of schizophrenia and other
mental disorders are often disruptive and distressing.
Their consequences are no less severe-truncated
education,  unemployment,  social isolation, and
exclusion from community participation. Facing
multiple life stressors, all severe, with a minimum of
.resources, people with severe mental illnesses often

need a variety of supportive services. Paramount among
these are housing, employment and income assistance,
and health benefits. Consumers have reported their
major needs to include adequate income, meaningful
employment, decent and affordable housing, quality
health care, and education to increase skills (Ball &
Havassy, 1984; Rosnow & Rucker, 1985; Lynch &
Kruzich, 1986).

Housing

Housing ranks as a priority concern of individuals with
serious mental illness. Locating affordable, decent, safe
housing is often difficult, and out of financial reach.
Stigma and discrimination also restrict consumer access
to housing. Despite legislation such as the Fair Housing
Act, allegations of housing discrimination based on
psychiatric disabilities are highly prevalent (U.S.
Department of Education, 1998). Landlords and public
housing programs are often unwilling to accept tenants
with severe mental disorders. In a survey of parents of
mentally ill adults, the dearth of decent and affordable
housing was a direct barrier to the person moving out
of the family home, even when all parties wanted it
(Hatfield, 1992).

The actual proportion of people with severe mental
illnesses who lack affordable and decent housing has
not been assessed directly. Yet indirect assessments
point to a serious problem, In 1994, the U.S.
Department of Housing and Urban Development
(HUD) reported that almost half of all very low-income
disabled residents-including persons with serious
mental illness-have "worst case" needs for housing
assistance. Furthermore, it was reported that the
majority of these persons often live in the most severely
inadequate housing (U.S. Department of Housing and
Urban Development, 1994; U.S. Department of
Education, 1998). It is estimated that up to one in three
individuals who experience homelessness has a mental
illness (Federal Interagency Task Force on
Homelessness and Mental Illness, 1992).
The housing preferences of people with
schizophrenia and other serious mental disorders are
clear: these individuals strongly desire their own decent
living quarters where they have control over who lives

292


with them and how decisions are made (Owen et al.,
1996; Schutt & Goldfinger, 1996; Sohng, 1996). In an
analysis of 26 consumer preference surveys, Tanzman
( 1993) found that at least 59 percent of those surveyed
wanted independent living in a house or apartment.
They also preferred to live alone (or with a spouse or
partner), yet not with other people with mental
disorders. Most also preferred access to mental health
and rehabilitation services to support them where they
were living.

  When deinstitutionalization led to the need for
more community housing, the residential programs that
were developed replicated institutional programs
(Carling, 1989). Although residential programs varied
in the degree of oversight and services, they generally
proved to be ineffective in meeting consumers' needs.
Moreover, living in such programs added to stigma.
Because of these shortfalls, greater emphasis has been
placed on conventional housing supplemented by
appropriate assistance tailored to individual need
(Srebnik et al., 1995). This new concept, called
supported housing, moves away from "placing" clients,
grouping clients by disability, staff monopolizing
decisionmaking, and use of transitional settings and
standardized levels of service (Carling, 1989; Lehman
& Newman, 1996). Instead, supported housing focuses
on consumers having a permanent home that is
integrated socially, is self-chosen, and encourages
empowerment and skills development. The services and
supports offered are individualized, flexible, and
responsive to changing consumer needs. Thus, instead
of fitting a person into a housing program "slot,"
consumers choose their housing, where they receive
support services. The level of support is expected to
fluctuate over time. With residents living in
conventional housing, some of the stigma attached to
group homes and residential treatment programs is
avoided.

Although there are no randomized clinical trials to
support the effectiveness of the supported housing
approach, consumer advocacy and changes in clinical
practice affirm the shift to supported housing. In a
quasi-experimental study, an evaluation of the Robert
Wood Johnson Foundation Program on Chronic Mental

Illness demonstrated the feasibility and modest benefits
of the supported housing approach using rental
subsidies from HUD (Newman et al., 1994).
Consumers experienced better mental health and more
self-determination when they lived in adequate housing
(Nelson et al., 1998). For example, one study found that
personal empowerment and functioning were enhanced,
and hospitalization reduced, after 5 months in a
supported housing program (McCarthy & Nelson,
1991). Also, resident control over decisions was
directly related to satisfaction and empowerment
(Seilheimer & Doyal, 19967. Similarly, another study
found that having greater choice in housing was
associated with greater happiness and life satisfaction
(Srebnik et al., 1995).

293

Despite these findings, serious housing problems
persist for people with schizophrenia and other mental
disorders. Most such individuals are poor and thereby
face very limited housing options.

Income, Education, and Employment
People with severe mental illnesses tend to be poor
(Polak & Warner, 1996). Although the reasons are not
understood, poverty is a risk factor for some mental
disorders, as well as a predictor of poor long-term
outcome among people already diagnosed (Cohen,
1993; Rabins et al., 1996; Saraceno & Barbui, 1997).
People with serious mental illnesses often become
dependent on public assistance shortly after their initial
hospitalization (Ho et al., 1997). They rely on
government disability-income programs, rent subsidies
(Loyd & Tsuang, 1985; Polak & Warner, 1996; Ho et
al., 1997), and informal sources of economic support
(e.g., living with parents). The unemployment rate
among adults with serious and persistent mental
disorders hovers at 90 percent (National Institute on
Disability and Rehabilitation Research, 1992).
Conversely, adequate standards of living and
employment are associated with better clinical
outcomes and quality of life (Cohen, 1993; Bell &
Lysaker, 1997). In a randomized trial of consumers
assigned to paid versus unpaid work, paid employment
was found to reduce symptoms of schizophrenia (Bell
et al., 1996). Moreover, employer accommodations for

Adults and Mental Health


Mental Health: A Report of the Surgeon General

those with psychiatric disabilities appear to be
inexpensive.  The most frequently requested
accommodations focus on orientation and training of
supervisors, provision of onsite support, and adaptive
work schedules. Such accommodations rarely result in
significant cost to the employer (Mancuso, 1990;
Fabian et al., 1993).

While newer vocational rehabilitation and
employment initiatives strive to remedy persistently
high levels of unemployment, most consumers find
themselves unable to work consistently or at all. This is
due not only to active symptoms but also to profound
interruptions of education and employment caused by
symptom onset and exacerbations, stigma and
discrimination, lack of higher education programs for
this population, and low-paying menial jobs.
When the onset of mental health-problems begins
during school-age years, educational systems are often
ill prepared. Several studies have identified educational
deficits in their clientele, who function in reading and
math at a level far below their achieved grades in
school (Cook et al., 1987; Cook & Solomon, 1993).
Supported education models can provide assistance to
consumers with their education (Cook & Solomon,
1993; Hoffman & Mastrianni, 1993; Ryglewicz &
Glynn, 1993). One example is Consumers and
Alliances United for Supported Education, aconsumer-
operated program in Quincy, Massachusetts, that
provides a wide range of services to encourage
individuals with psychiatric disabilities to enter or
reenter college or technical school programs. Services
include academic and career counseling, assistance
with finding financial aid, study skills, stress control,
tutoring/coaching, and assistance with crisis while
hospitalized (CMHS, 1996).

  Consumers lack control over their financial affairs
when benefit checks are given directly to care providers
for the person's housing and other expenses, or to a
legally appointed representative payee (if the person
has been deemed unable to manage his/her own
finances) (Conrad et al., 1998). Those consumers who
manage their own finances usually face such modest
monthly budgets that there is no room for error. Funds
frequently are depleted before the end of the month.

Furthermore, disability payments are sometimes
reduced or discontinued when a recipient is working.
Since employment is rarely consistent, they need to
resume disability benefits. Yet, once they are canceled,
government disability benefits can be cumbersome to
restart. The Social Security Administration has
developed new measures to facilitate reactivation of
benefits for individuals who return to work, but they
are not yet widely disseminated. In some ways the
requirements of Social Security disability benefits and
other such programs often act as disincentives to the
pursuit of employment (Polak & W+uner, 1996; Priebe
et al., 1998).

Some people with serious mental illnesses have
adequate income or fmancial assistance (Ware &
Goldfinger, 1997). Some have affluent families who
can subsidize their expenses. Others collect pensions
because they were not disabled by their illness until
after they had a substantial work history. Finally, some
have found well-paying positions through a formal
rehabilitation program, a community-based educational
or vocational training program, or a supportive
employer.

294

Health Coverage

Health coverage goes hand in hand with housing and
income in determining standards of living for people
with serious psychiatric disabilities. Due to their low
incomes and the high cost of psychiatric and other
health services, most people with schizophrenia and
other forms of severe and persistent mental disorders
rely on Medicare, Medicaid, and other government
programs to cover their therapeutic services,
medications, and other health care. When reductions or
loss of these benefits curtail access to needed
medication or services, clients' health suffers and their
use of more expensive emergency services increases
(Soumerai et al., 1994). Even when they have access to
health insurance coverage, individuals with a mental
disorder encounter barriers to procuring that insurance
and in receiving general medical care (Druss &
Rosenheck 1998).


Integrating Service Systems
Integrating the range of services needed by individuals
with severe and persistent mental disorders has been a
vexing problem for decades. The General Accounting
Office (1977) criticized the Federal community mental
health centers for their failure to meet the multiple
needs of individuals with chronic mental illness. The
Federal response was to establish a Community
Support Program to provide resources and technical
assistance to communities to help them in formulating
community support systems to integrate the various
services provided by fragmented human services
agencies (Turner & TenHoor, 1978; Tessler &
Goldman, 1982). The limitations of a community
support program in dealing with severe and persistent
mental illness in major cities, particularly those with
high rates of homelessness, prompted the Robert Wood
Johnson Foundation to partner with HUD to create the
Programon Chronic Mental Illness (Aiken et al., 1986).
This program promoted the concept of local mental
health authorities as the agencies responsible for
integrating all services for individuals with chronic
mental illness, including housing opportunities (Shore
& Cohen, 1990, 1994). The Robert Wood Johnson
Foundation Program on Chronic Mental Illness was
initiated in late 1986 and evaluated over a 6-year period
(Goldman et al., 1990a, 199Ob, 1994a, 1994b).
  The evaluation determined that local mental health
authorities were established or strengthened in almost
all of the nine cities, resulting in measurable increases
in organizational centralization and reduced
fragmentation of services (Morrissey et al., 1994). Case
management services also were expanded, producing
greater continuity of care and reductions in family
burden (Lehman et al., 1994; Shem et al., 1994; Tessler
et al., 1994). Client outcomes, including social
functioning and quality of life measures, improved
during the demonstration (Lehman et al., 1994; Shem
et al., 1994). Yet the time course of most clients'
improvement did not coincide with improvements in
system integration.  This suggested that their
improvement could not be attributed to system
integration. For a subset of clients, improved client
outcomes were due to the benefits of special combined

Adults and Mental Health

housing and support services. Yet, even for this subset,
improvements  were related,  but not directly
attributable, to systems integration (Newman et al.,
1994).

Evaluators concluded that system integration and
traditional case management alone probably were not
sufficient to produce optimal social and clinical
outcomes (Goldman et al., 1994b; Lehman et al., 1994).
They speculated that the availability of rental subsidies
and supports or more intensive and higher quality case
management services-such as those offered in
assertive community treatment-were essential
(Ridgely et al., 1996). This set of findings, coincident
with the release of the report of the Federal Interagency
Task Force on Homelessness and Mental Illness
(1992), Ourcasts on Main Street, prompted the
development of another demonstration program.
Access to Community Care and Effective Services
and Supports was launched by the Federal Center for
Mental Health Services in 1993 (Randolph et al.,
1997). Still in the midst of its evaluation, preliminary
findings sustain the benefits of providing assertive
community treatment to obtain good clinical and social
outcomes. They support the association of better
system integration with higher rates of moving
individuals with severe mental illness from
homelessness into independent housing (Rosenheck et
al., 1998a). It remains to be seen, however, whether the
improvements in system integration observed over time
are associated with improvements in consumers'
clinical and social outcomes.

Integrating service systems remains a challenge to
mental health and related human service agencies. Its
benefits for accountability and centralization of
authority have been established. Its impact on
individuals with severe and persistent mental illness
may be limited by the lack of available high-quality
services and mainstream welfare resources, reflecting
the gap between what can be done and what is available
(Goldman, 1998a).

295


Mental Health: A Report of the Surgeon General

Conclusions
1. As individuals move into adulthood, developmental
goals focus on productivity and intimacy including
pursuit of education, work, leisure, creativity, and
personal relationships. Good mental health enables
individuals to cope with adversity while pursuing
these goals.

2. Untreated, mental disorders can lead to lost
productivity,  unsuccessful relationships, and
significant distress and dysfunction. Mental illness
in adults can have a significant and continuing
effect on children in their care.
3. Stressful life events or the manifestation of mental
illness can disrupt the balance adults seek in life
and result in distress and dysfunction. Severe or
life-threatening trauma experienced either in
childhood or adulthood can further provoke
emotional and behavioral reactions that jeopardize
  mental health.

4.

5.

6.

7.

Research has improved our understanding of
mental disorders in the adult stage of the life cycle.
Anxiety, depression, and schizophrenia,
particularly, present special problems in this age
group. Anxiety and depression contribute to the
high rates of suicide in this population.
Schizophrenia is the most persistently disabling
condition, especially for young adults, in spite of
recovery of function by some individuals in mid to
late life.

Research has contributed to our ability to
recognize, diagnose, and treat each of these
conditions effectively in terms of symptom control
and behavior management. Medication and other
therapies can be independent, combined, or
sequenced depending on the individual's diagnosis
and personal preference.
A new recovery perspective is supported by
evidence on rehabilitation and treatment as well as
by the personal experiences of consumers.
Certain common events of midlife (e.g., divorce or
other stressful life events) create mental health
problems (not necessarily disorders) that may be
addressed through a range of interventions.

8. Care and treatment in the real world of practice do
not conform to what research determines as best.
For many reasons, at times care is inadequate but
there are models for improving treatment.
9. Substance abuse is a major co-occurring problem
for adults with mental disorders, Evidence supports
combined treatment, although there are substantial
gaps between what research recommends and what
typically is available in communities.
10. Several special problems in care and treatment of
adults have been recognizec, beyond traditional
mainstream mental health concerns, including
racial and ethnic differences, lack of consumer
involvement, and the consequences of disability
and poverty.

11. Barriers of access exist in the organization and
financing of services for adults. There are specific
problems with Medicare, Medicaid, income
supports, housing, and managed care.

References

Aagaard, J., Vestergaard, P., & Maarbjerg, K. (1988).
Adherence to lithium prophylaxis: II. Multivariate
analysis of clinical, social, and psychosocial predictors
of nonadherence. Phmmacopsychiatry, 21.166-170.
Abbruzzese, M., Ferri, S., & Scarone, S. (1997). The
selective breakdown of frontal functions in patients with
obsessive-compulsive disorder and in patients with
schizophrenia: A double dissociation experimental
finding. Neuropsychologia, 35,907-912.
Abram, K., & Teplin, L. (1991). Co-occurring disorders
among mentally ill jail detainees: Implications for public
policy. American Psychologist, 46, 1036-1046.
Adams, W., Kendell, R. E., Hare, E. H., & Murk-Jorgensen,
P. (1993). Epidemiological evidence that maternal
influenza contributes to the aetiology of schizophrenia.
An analysis of Scottish, English, and Danish data.
  British Joumul of Psychiatry, 163, 522-534.
Adolphs, R., Tranel, D., & Damasio, A. R. (1998). The
human amygdala in social judgement. Nature, 393,
  470-474.

Agency for Health Care Policy and Research. (1999).
Treatment of depression-newer phamcotherapies
(Evidence Report/Technology Assessment, Number 7,
Pub. No. 99-E014). Rockville, MD: Author.

296


Adults and Mental Health

Aguglia, E., Casacchia, M., Cassano, G. B., Faravelli, C.,
Ferrari, G., Giordano, P., Pancheri, P., Ravizza, L.,
Trabucchi, M., Bolino, F., Scarpato, A., Berardi, D.,
Provenzano, G., Brugnoli, R., & Rozzini, R. (1993).
Double-blind study of the efficacy and safety of
sertraline versus fluoxetine in major depression.
International Clinical Psychopharmacology, 8,
  197-202. .

Aiken, L., Somers, S., & Shore, M. (1986). Private
foundations in health affairs: A case study of a national
initiative for the chronically mentally ill. American
Psychologist. 41, 1290-1295.

Akbarian, S., Bunney, W. E. J., Potkin, S. G., Wigal, S. B.,
Hagman, J. 0.. Sandman, C. A., &Jones, E. G. (1993).
  Altered distribution  of nicotinamide-adenine
dinucleotide phosphate-diaphorase cells in frontal lobe
of schizophrenics implies disturbances of cortical
development. Archives of General Psychiatry, 50,
  169-177.

Akiskal, H. S. (1985). Interaction of biologic and
psychologic factors in the origin of depressive disorders.
Acfa PsychiarricaScandinavica., 319(Suppl.), 13 1-139.
Alexander, M. J. (1996). Women with co-occurring addictive
and mental disorders: An emerging profile of
vulnerability. American Journal of Orthopsychiatry, 66,
  61-70.

Alexander, P. C., Neimeyer, R. A., & Follette, V. M. (1991).
Group therapy for women sexually abused as children:
Controlled study and investigation of individual
differences. Journal of Interpersonal Violence, 6,
  218-231.

Alexander, P. C., Neimeyer, R. A., Follette, V. M., Moore,
M. K., & Harter, S. (1989). A comparison of group
treatments of women sexually abused as children.
Journal of Consulting and Clinical Psychology, 57,
  479-483.

Allness, D. & Knoedler, W. (1999). Recommended PACT
standards for new teams [On-line]. Available:
http://www.nami.org/ about/pactstd.html
Alloy, L. B., & Abramson, L. Y. (1988). Depressive realism:
Four theoretical perspectives. In Alloy L. B. (Ed.),
Cognitive processes in depression (pp. 223-265). New
  York: Guilford Press.

Alloy, L. B., Peterson, C., Abramson, L. Y., & Seligman, M.
E. (1984). Attributional style and the generality of
learned helplessness. Journal of Personality and Social
Psychology, 46,68 l-687.

American Psychiatric Association. (1993). Practice guidehe
for major depressive disorder in adults. American
Journal of Psychiarry, ZSO(Suppl.4), l-26.
American Psychiatric Association (1994). Diagno,rtic and
statistical manual of mental disorders (4th ed.).
Washington, DC: Author

American Psychiatric Association. (1998). Practice
  guidelines for the treatment of patients with panic
  disorder. American Journal of Psychiatry, I55(Suppl.
  12), l-34.

Andersson, C., Chakos, M., Mailman, R., & Lieberman, J.
(1998). Emerging roles for novel antipsychotic
medications in the treatment of schizophrenia.
Psychiatric Clinics of North America, 21, 151-179.
Andrade, C., Gangadhar, B. N., Subbakrishna, D. K.,
  Channabasavanna, S. M., & Pradhan, N. (1998). A
double-blind comparision of sinusoidal wave and brief-
pulse electroconvulsive therapy in endogenous depres-
sion. Convulsive Therapy, 4,291-305.
Andreasen, N. C. (1995). Symptoms, signs, and diagnosis of
schizophrenia. Lancer, 346,477B48 1.
Andreasen, N. C. (1997a). The evolving concept of
schizophrenia: From Kraepelin to the present and future.
Schizophrenia Research, 28, 105-109.
Andreasen, N. C. (1997b). Linking mind and brain in the
study of mental illnesses: A project for a scientific
psychopathology. Science, 27.5, 1586-1593.
Andreasen, N. C., O'Leary, D. S., Cizadlo, T., Amdt, S.,
  Rezai, K., Ponto, L. L., Watkins, G. L., & Hichwa, R. D.
  (1996). Schizophrenia and cognitive dysmetria: A
positron-emission tomography study of dysfunctional
prefrontal-thalamic-cerebellar circuitry. Proceedings of
  the National Academy of Sciences of the United Stares
  of America, 93,9985-9990.

Andreasen, N. C., O'Leary, D. S., Flaum, M., Nopoulos, P.,
Watkins, G. L., Boles Ponto, L. L., & Hichwa, R. D.
(1997). Hypofrontality in schizophrenia: Distributed
dysfunctional circuits in neuroleptic-naive patients.
  Lancer, 349, 1730-1734.

Andreasen, N. C., Paradiso, S., & O'Leary, D. S. (1998).
"Cognitive dysmetria" as an integrative theory of
schizophrenia: A dysfunction in cortical-subcortical-
cerebellar circuitry? Schizophrenia Bulletin, 24,
  203-218.

Andrews, G. (1995). Workforce deployment: Reconciling
demands and resources. Australian and New Zealand
Journal of Psychiatry, 29, 394-402.

297


Mental Health: A Report of the Surgeon General

Angst, J., Angst, F., & Stassen, H. H. (1999). Suicide risk in
patients with major depressive disorder. Journal of
Clinical Psychiatry, 6O(Suppl. 2), 57-62.
Appleby, L., Desai, P. N., Luchins, D. J., Gibbons, R. D., &
Hedeker, D. R. (1993). Length of stay and recidivism in
schizophrenia: A study of public psychiatric hospital
patients. American Journal of Psychiatry, 150, 72-76.
Arborelius, L., Owens, M. J., Plotsky, P. M., & Nemeroff, C.
B. (1999). The role of corticotropin-releasing factor in
depression and anxiety disorders. Journal of
  Endocrinology, 160, 1-12.

Am&age, R., Rush, A. J., Trivedi, M., Cain, J., & Roffwarg,
H. P. (1994). The effects of nefazodone on sleep
architecture in depression. Neuropsychopharmacology,
  IO, 123-127.

Arnold, S. E., Hyman, B. T., Van Hoesen, G. W., &
  Damasio, A. R. (1991). Some cytoarchitectural
abnormalities of the entorhinal cortex in schizophrenia.
Archives of General Psychiatry, 48,625-632.
Ascher, J. A., Cole, J. O., Colin, J. N., Feighner, J. P., Ferris,
R. M., Fibiger, H. C., Golden, R. N., Martin, P., Potter,
W. Z., Richelson, E., & Sulser, F. (1995). Bupropion: A
review of its mechanism of antidepressant activity.
  Journal of Clinical Psychiatry, 56, 395-401.
Attkisson, C., Cook, J., Karno, M., Lehman, A., McGlashan,
  T. H., Meltzer, H. Y., O'Connor, M., Richardson, D.,
  Rosenblatt, A., Wells, K., & Williams, J., & H6hmann,
  A. A. (1992). Clinical services research. Schizophrenia
  Bulletin, 18, 561-626.

Awad, G. A., Voruganti, L. N., & Heslegrave, R. J. (1997).
Measuring quality of life in patients with schizophrenia.
  Pharmacoeconomics, 11,3247.
Baldessarini, R. J., Cohen, B. M., & Teicher, M. H. (1990).
Pharmacological treatment. In S. T. Levy 62 P. T Ninan
(Eds.), Schizophrenia: Treatment of acute psychotic
episodes (pp. 61-118). Washington, DC: American
  Psychiatric Press.

Baldwin, D. S., & Birtwistle, J. (1998). The side effect
burden associated with drug treatment of panic disorder.
Journal of Clinical Psychiatry, 59(Suppl. 8), 394.
Ball, F. L., & Havassy, B. E. (1984). A survey of the
problems and needs of homeless consumers of acute
psychiatric services.  Hospital and Community
  Psychiatry, 35,9 17-92 1.

Ballenger, J. C., Davidson, J. R., Lecrubier, Y., Nutt, D. J.,
Bobes, J., Beidel, D. C., Ono, Y., & Westenberg, H. G.
(1998). Consensus statement on social anxiety disorder
from the International Consensus Group on Depression
and Anxiety. Journal of Clinical Psychiatry, 59(Suppl.
  17), 54-60.

Ballus, C. (1997). Effects of antipsychotics on the clinical
and psychosocial  behavior of patients with
schizophrenia. Schizophrenia Research, 28,247-255.
Bandura, A. (1977). Self-efficacy: Toward aunifying theory
of behavioral change. Psychological Review, 84,
  191-215.

Barbee, J. G. (1998). Mixed symptoms and syndromes of
anxiety and depression: Diagnostic, prognostic, and
etiologic issues. Annals of Clinical Psychiatry, 10,
  15-29.

Barlow, D. H. (1988). Anxiety and ifs disorders: The nature
and treatment of anxiety andpanic. New York: Guilford
  Press.

Barlow, D. H., Chorpita, B. F., & Turovsky, J. (1996). Fear,
panic, anxiety, and disorders of emotion. In D. A. Hope
(Ed.), Perspectives on anxiety, panic, andfear (The 43rd
Annual Nebraska Symposium on Motivation, pp.
  251-328). Lincoln, NE: Nebraska University Press.
Barlow, D. H., & Lehman, C. L. (1996). Advances in the
psychosocial treatment of anxiety disorders. Implications
for national health care. Archives of General Psychiafly,
  53.727-735.

Barnes, T. R., & McPhillips, M. A. (1998). Novel
antipsychotics, extrapyramidal side effects and tardive
dyskinesia. International Clinical Psychopharmacology,
13(Suppl. 3), s49s57.

Baron, M. (1997). Genetic linkage and bipolar affective
disorder: Progress and pitfalls. Molecular Psychiatry, 2,
  200-210.

Barta, P. E., Pearlson, G. D., Powers, R. E., Richards, S. S.,
& Tune, L. E. (1990). Auditory hallucinations and
smaller superior temporal gyral volume in schizophrenia.
American Journal of Psychiatry, 147,1457-1462.
Bartels, S. J., Drake, R. E., & Wallach, M. A. (1995). Long-
term course of substance use disorders among patients
with severe mental illness. Psychiatric Services, 46,
  248-251.

Basso, M. R., Nasrallah, H. A., Olson, S. C., & Bomstein, R.
A. (1997). Cognitive deficits distinguish patients with
  adolescent-  and adult-onset schizophrenia.
Neuropsychiatry, Neuropsychology, and Behavioral
Neurology, 10, 107-l 12.

298


Adults and Mental Health

Basso, M. R., Nasrallah, H. A., Olson, S. C., & Bomstein, R.
A. (1998). Neuropsychological correlates of negative,
disorganized and psychotic symptoms in schizophrenia.
Schizophrenia Research, 31,99-l 11.
Bauer, M. S., Calabrese. J., Dunner, D. L., Post, R.,
Whybrow, P. C., Gyulai, L., Tay, L. K., You&in, S. R.,
Bynum, D., Lavori, P., & Price, R. A. (1994). Multisite
data reanalysis of the validity of rapid cycling as a
course modifier for' bipolar disorder in DSM-IV.
American Journal of Psychiatry, 151,506-515.
Baxter, L. R., Jr., Mazziotta, J. C., Phelps, M. E., Selin, C.
  E., Guze, B. H., & Fairbanks, L. (1987). Cerebral
glucose metabolic rates in normal human females versus
  normal males. Psychiatry Research, 21,237-245.
Beardslee, W. R., & Vaillant, G. (1997). Adult development.
  In A. Tasman, J. Kay, & J. A. Lieberman (Eds.),
  Psychiatry (Vol. `1, pp. 145-155). Philadelphia: W. B.
  Saunders.

Beasley, C. M., Jr., Domseif, B. E., Bosomworth, J. C.,
Sayler, M. E., Rampey, A. H., Jr., Heiligenstein, J. H.,
Thompson, V. L., Murphy, D. J., & Masica, D. N.
(1991). Fluoxetine and suicide: A meta-analysis of
controlled trials of treatment for depression. British
  Medical Journal, 303,685-692.
Beasley, C. M., Jr., Sayler, M. E., Cunningham, G. E.,
  Weiss, A. M., & Masica, D. N. (1990). Fluoxetine in
tricyclic refractory major depressive disorder. Journal of
Affective Disorders, 20, 193-200.       .
Bebbington, P., & Kuipers, L. (1994). The predictive utility
  of expressed emotion in schizophrenia: An aggregate
  analysis. Psychological Medicine, 24, 707-718.
Beck, A. T. (1976). Cognitive therapy and the emotional
  disorders. New York: International Universities Press.
Beck, A. T., Rush A. J., & Shaw B. F. (1979). Cognitive
  therapy of depression. New York: Guilford Press.
Bell, C. C. & Mehta, H. (1981). The misdiagnosis of black
  patients with manic depressive illness. Journal of the
  National Medical Association 73, 101-107.
Bell, M. D., & Lysaker, P. H. (1997). Clinical benefits of
  paid work activity in schizophrenia: l-year followup.
  Schizophrenia Bulletin, 23,3 17-328.
Bell, M. D., Lysaker, P. H., & Milstein, R. M. (1996).
Clinical benefits of paid work activity in schizophrenia.
  Schizophrenia Bulletin, 22,s l-67.
Bell, M. D., & Ryan, E. R. (1984). Integrating psychosocial
  rehabilitation into the hospital psychiatric service.
  Hospital and Community Psychiatry, 35, 1017-1022.

Bellack, A. S., & Gearon, J. S, (1998). Substance abuse
treatment for people with schizophrenia. Addictive
  Behaviors, 23, 749-766.

Bellack, A. S., Morrison, R. L., & Mueser, K. T. (1989).
Social problem solving in schizophrenia. Schizophrenia
  Bulletin, 15, 101-l 16.

Bellack, A. S., & Mueser, K. T. (1993). Psychosocial
treatment for schizophrenia. Schizophrenia Bulletin, 19,
  317-336.

Berren, M., Hill, K., Merikle, E., Gonzalez, N., & Santiago,
J. (1994). Serious mental illness and mortality rates.
Hospital and Community Psychiatry, 45,604-605.
Bertelsen, A., Harvald, B., & Hauge, M. (1977). A Danish
twin study of manic-depressive disorders. British
Journal of Psychiatry, Z30, 330-35 1.
Besio, S. W., & Mahler, J. (1993). Benefits and challenges
of using consumer staff in supported housing services.
Hospital and Community Psychiatry, 44,490-491.
Bezold, H. S., MacDowell M., & Kunkel R. (1996).
Predicting psychiatric length of stay. Administration and
  Policy in Mental Health, 23,407-423.
Bierut, L. J., Heath, A. C., Bucholz, K. K., Dinwiddie, S. H.,
  Madden, P. A., Statham, D. J., Dunne, M. P., & Martin,
N. G. (1999). Major depressive disorder in a
community-based twin sample: Are there different
  genetic and environmental contributions for men and
  women? Archives of General Psychiatry, 56,557-563.
Black, D. W., Winokur, G., & Nasrallah, A. (1987). The
  treatment of depression: Electroconvulsive therapy v
  antidepressants: A naturalistic evaluation of 1,495
  patients. Comprehensive Psychiatry, 28, 169-182.
Blackbum, I. M., Eunson, K. M., & Bishop, S. (1986). A
  two-year naturalistic follow-up of depressed patients
  treated with cognitive therapy, pharmacotherapy and a
  combination of both. Journal ofA#ktive Disorders, 10,
   67-75.

Blanchard, J. J., Mueser, K. T., & Bellack, A. S. (1998).
Anhedonia, positive and negative affect, and social
functioning in schizophrenia. Schizophrenia Bulletin,
  24,413-424.

Blehar, M. C., DePaulo, J. R. Jr, Gershon, E. S., Reich, T.,
Simpson, S. G., & Numberger, J. I. Jr. (1998). Women
with bipolar disorder: Findings from the NIMH Genetics
Initiative sample. Psychophamacology Bulletin, 347
  239-243.

Bloom, F. E. (1993). Advancing a neurodevelopmental
origin for schizophrenia. Archives of General
Psychiatry, 50,224-227.

299


Mental Health: A Report of the Surgeon General

Blumenthal, S. J. (1988). Suicide: A guide to risk factors,
assessment, and treatment of suicidal patients. Medical
  Clinics of North America, 72, 937-97 1.
Blumenthal, S. J. (1994a). Gender differences in mental
disorders. Journal of Clinical Psychiatry, 3,453-458.
Blumenthal, S. J. (1994b). Women and depression. Journal
of WomenS Health, 3,467-453.
Bogerts, B., Lieberman, J. A., Ashtari, M., Bilder, R. M.,
Degreet, G., & Lemer; G. (1993). Hippocampus-
amygdala volumes and psychopathology in chronic
  schizophrenia. Biological Psychiatry, 33, 236-246.
Bolden-Watson. C., & Richelson, E. (1993). Blockade by
  newly-developed antidepressants of biogenic amine
  uptake into rat brain synaptosomes. Life Sciences, 52,
  1023-1029.

Bond, G. R., & Dincin, J. (1986). Accelerating entry into
transitional employment in a psychosocial rehabilitation
agency. Rehabilitation Psychology, 31, 143-154.
Bond, G. R., Drake, R. E., Mueser, K. T., & Becker, D. R.
(1997). An update on supported employment for people
with severe mental illness. Psychiatric Services, 48,
  335-346.

Bond, G. R., McGrew, J. H., & Fekete, D. M. (1995).
Assertive outreach of frequent users of psychiatric
hospitals: A meta-analysis. Journal of Mental Health
  Administration, 22,4-16.

Borkman, T. J. (1997). A selected look at self-help groups in
the U.S. Health and Social Care in the Community, 5,
  357-364.

Borkman, T. J. (1991). Self-help groups. Introduction to the
special issue. American Journal of Community
  Psychology, 19,643-650.

Borland, A., McRae, J., & Lycan, C. (1989). Outcome of
five years of continuous intensive case management.
Hospital and Community Psychiatry, 40, 369-376.
Bowden, C. L., Brugger, A. M., Swarm, A. C., Calabrese, J.
  R., Janicak, P. G., Petty, F., Dilsaver, S. C., Davis, J.
  M., Rush, A. J., Small, J. G., Garza-Trevifio, E. S.,
  Risch, S. C., Goodnick, P. J., & Morris, D. D. (1994).
Efficacy of divalproex vs lithium and placebo in the
treatment of mania. The Depakote Mania Study Group.
  Journal of the American Medical Association, 271,
  918-924.

Bracha, H. S. (1991). Etiology of structural asymmetry in
schizophrenia: An alternative hypothesis. Schizophrenia
  Bulletin, 17, 55 l-553.

Braun, C. M., Lapierre, D., Hodgins, S., Toupin, J., Reveille,
S., & Constantineau, C. (1995). Neurological soft signs
in schizophrenia: Are they related to negative or positive
  symptoms,  neuropsychological performance and
violence? Archives of Clinical Neuropsychology, IO,
  489-509.

Brawman-Mintzer, O., & Lydiard, R. B; (1996). Generalized
anxiety disorder: Issues in epidemiology. Journal of
Clinical Psychiatry, 57(Suppl. 7), 3-8.
Brazo, P., & Dollfus, S. (1997). Syndromic and diagnostic
heterogeneity of schizophrenia. Encephafe, 23,20-24.
Breggin, P. R., & Breggin, G. R. (1994). Talking back to
  Prozac. New York: St. Martin's Press.
Breiter, H. C., Etcoff, N. L., Whalen, P. J., Kennedy, W. A.,
Rauch, S. L., Buckner, R. L.. Strauss, M. M., Hyman, S.
E., & Rosen, B. R. (1996). Response and habituation of
the human amygdala during visual processing of facial
expression. Neuron, 17,875-887.
Brekke, J. S., & Bar&, C. (1997). Cross-ethnic symptom
differences in schizophrenia: The influence of culture
and minority status. Schizophrenia Bulletin, 23,
  305-316.

Brekke, J. S., Raine, A., & Thomson, C. (1995). Cognitive
and psychophysiological correlates of positive, negative,
and disorganized symptoms in the schizophrenia
spectrum. Psychiatry Research, 57,241-250.
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E.
(199 1). Traumatic events and posttraumatic stress
disorder in an urban population of young adults.
Archives of General Psychiatry, 48,2 16-222.
Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R.,
  Davis, G. C., & Andreski, P. ( 1998). Trauma and
  posttraumatic stress disorder in the community: The
  1996 Detroit Area Survey of Trauma. Archives of
  General Psychiatry, 55, 626-632.
Briere J. (1992). Chiid a&use trauma: Theory and treatment
  of the lasting effects. Newbury Park, CA: Sage.
Brixey, S. N., Gallagher, B. J., III, McFalls, J. A., Jr., &
  Parmelee, L. F. (1993). Gestational and neonatal factors
  in the etiology of schizophrenia. Journal of Clinical
  Psychology, 49,447-456.

Broadhead, W. E., Blazer, D. G., George, L. K., & Tse, C. K.
(1990). Depression, disability days, and days lost from
work in a prospective epidemiologic survey. Journal of
  the American Medical Association, 264,2524-2528.
Brown, G. W., & Harris, T. 0. (1989). Life events and
  illness. New York: Guilford Press.

300