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The Center for Mental Health Services

Substance Abuse and Mental Health 

Services Administration National Institutes of Health

For sale by the Superintendent of Documents,

P.O. Box 371954, Pittsburgh, PA 15250–7954

Suggested Citation

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon

General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, 

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 

National Institutes of Health, National Institute of Mental Health, 1999.
		



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The United States leads the world in understanding the importance of overall health and wellbeing to the strength of a Nation and its people. What we are coming to realize is that mental health

is absolutely essential to achieving prosperity. According to the landmark “Global Burden of

Disease” study, commissioned by the World Health Organization and the World Bank, 4 of the 10

leading causes of disability for persons age 5 and older are mental disorders. Among developed

nations, including the United States, major depression is the leading cause of disability. Also near

the top of these rankings are manic-depressive illness, schizophrenia, and obsessive-compulsive

disorder. Mental disorders also are tragic contributors to mortality, with suicide perennially

representing one of the leading preventable causes of death in the United States and worldwide.

The U.S. Congress declared the 1990s the Decade of the Brain. In this decade we have learned

much through research—in basic neuroscience, behavioral science, and genetics—about the complex

workings of the brain. Research can help us gain a further understanding of the fundamental

mechanisms underlying thought, emotion, and behavior—and an understanding of what goes wrong

in the brain in mental illness. It can also lead to better treatments and improved services for our

diverse population.

Now, with the publication of this first Surgeon General’s Report on Mental Health, we are

poised to take what we know and to advance the state of mental health in the Nation. We can with

great confidence encourage individuals to seek treatment when they find themselves experiencing

the signs and symptoms of mental distress. Research has given us effective treatments and service

delivery strategies for many mental disorders. An array of safe and potent medications and

psychosocial interventions, typically used in combination, allow us to effectively treat most mental

disorders. 

This seminal report provides us with an opportunity to dispel the myths and stigma surrounding

mental illness. For too long the fear of mental illness has been profoundly destructive to people’s

lives. In fact mental illnesses are just as real as other illnesses, and they are like other illnesses in

most ways. Yet fear and stigma persist, resulting in lost opportunities for individuals to seek

treatment and improve or recover. 

In this Administration, a persistent, courageous advocate of affordable, quality mental health

services for all Americans is Mrs. Tipper Gore, wife of the Vice President. We salute her for her

historic leadership and for her enthusiastic support of the initiative by the Surgeon General, Dr.

David Satcher, to issue this groundbreaking Report on Mental Health.

The 1999 White House Conference on Mental Health called for a national antistigma campaign.

The Surgeon General issued a Call to Action on Suicide Prevention in 1999 as well. This Surgeon

General’s Report on Mental Health takes the next step in advancing the important notion that mental

health is fundamental health.




Since the turn of this century, thanks in large measure to research-based public health

innovations, the lifespan of the average American has nearly doubled. Today, our Nation’s physical

health—as a whole—has never been better. Moreover, illnesses of the body, once shrouded in

fear—such as cancer, epilepsy, and HIV/AIDS to name just a few—increasingly are seen as treatable,

survivable, even curable ailments. Yet, despite unprecedented knowledge gained in just the past three

decades about the brain and human behavior, mental health is often an afterthought and illnesses of

the mind remain shrouded in fear and misunderstanding. 

This Report of the Surgeon General on Mental Health is the product of an invigorating

collaboration between two Federal agencies. The Substance Abuse and Mental Health Services

Administration (SAMHSA), which provides national leadership and funding to the states and many

professional and citizen organizations that are striving to improve the availability, accessibility, and

quality of mental health services, was assigned lead responsibility for coordinating the development

of the report. The National Institutes of Health (NIH), which supports and conducts research on

mental illness and mental health through its National Institute of Mental Health (NIMH), was pleased

to be a partner in this effort. The agencies we respectively head were able to rely on the enthusiastic

participation of hundreds of people who played a role in researching, writing, reviewing, and

disseminating this report. We wish to express our appreciation and that of a mental health

constituency, millions of Americans strong, to Surgeon General David Satcher, M.D., Ph.D., for

inviting us to participate in this landmark report.

The year 1999 witnessed the first White House Conference on Mental Health and the first

Secretarial Initiative on Mental Health prepared under the aegis of the Department of Health and

Human Services. These activities set an optimistic tone for progress that will be realized in the years

ahead. Looking ahead, we take special pride in the remarkable record of accomplishment, in the

spheres of both science and services, to which our agencies have contributed over past decades. With

the impetus that the Surgeon General’s report provides, we intend to expand that record of

accomplishment. This report recognizes the inextricably intertwined relationship between our mental

health and our physical health and well-being. The report emphasizes that mental health and mental

illnesses are important concerns at all ages. Accordingly, we will continue to attend to needs that

occur across the lifespan, from the youngest child to the oldest among us.

The report lays down a challenge to the Nation—to our communities, our health and social

service agencies, our policymakers, employers, and citizens—to take action. SAMHSA and NIH look

forward to continuing our collaboration to generate needed knowledge about the brain and behavior

and to translate that knowledge to the service systems, providers, and citizens.

Nelba Chavez, Ph.D. Steven E. Hyman, M.D.

Administrator Director

Substance Abuse and Mental Health National Institute of Mental Health

 Services Administration for The National Institutes of Health

Bernard S. Arons, M.D.

Director

Center for Mental Health Services



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The past century has witnessed extraordinary progress in our improvement of the public health

through medical science and ambitious, often innovative, approaches to health care services. Previous

Surgeons General reports have saluted our gains while continuing to set ever higher benchmarks for

the public health. Through much of this era of great challenge and greater achievement, however,

concerns regarding mental illness and mental health too often were relegated to the rear of our

national consciousness. Tragic and devastating disorders such as schizophrenia, depression and

bipolar disorder, Alzheimer’s disease, the mental and behavioral disorders suffered by children, and

a range of other mental disorders affect nearly one in five Americans in any year, yet continue too

frequently to be spoken of in whispers and shame. Fortunately, leaders in the mental health

field—fiercely dedicated advocates, scientists, government officials, and consumers—have been

insistent that mental health flow in the mainstream of health. I agree and issue this report in that spirit.

This report makes evident that the neuroscience of mental health—a term that encompasses

studies extending from molecular events to psychological, behavioral, and societal phenomena—has

emerged as one of the most exciting arenas of scientific activity and human inquiry. We recognize

that the brain is the integrator of thought, emotion, behavior, and health. Indeed, one of the foremost

contributions of contemporary mental health research is the extent to which it has mended the

destructive split between “mental” and “physical” health. 

We know more today about how to treat mental illness effectively and appropriately than we

know with certainty about how to prevent mental illness and promote mental health. Common sense

and respect for our fellow humans tells us that a focus on the positive aspects of mental health

demands our immediate attention. 

Even more than other areas of health and medicine, the mental health field is plagued by

disparities in the availability of and access to its services. These disparities are viewed readily through

the lenses of racial and cultural diversity, age, and gender. A key disparity often hinges on a person’s

financial status; formidable financial barriers block off needed mental health care from too many

people regardless of whether one has health insurance with inadequate mental health benefits, or is

one of the 44 million Americans who lack any insurance. We have allowed stigma and a now

unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect

these barriers. It is time to take them down.

Promoting mental health for all Americans will require scientific know-how but, even more

importantly, a societal resolve that we will make the needed investment. The investment does not call

for massive budgets; rather, it calls for the willingness of each of us to educate ourselves and others

about mental health and mental illness, and thus to confront the attitudes, fear, and misunderstanding

that remain as barriers before us. It is my intent that this report will usher in a healthy era of mind and

body for the Nation.

David Satcher, M.D., Ph.D.

Surgeon General


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Mental health—the successful performance of mental function, resulting in productive activities, fulfilling

relationships with other people, and the ability to adapt to change and to cope with adversity; from early

childhood until late life, mental health is the springboard of thinking and communication skills, learning,

emotional growth, resilience, and self-esteem. 

Mental illness—the term that refers collectively to all mental disorders. Mental disorders are health

conditions that are characterized by alterations in thinking, mood, or behavior (or some combination

thereof) associated with distress and/or impaired functioning. 

This is the first Surgeon General’s report ever issued

on the topic of mental health and mental illness.

The science-based report conveys several messages.

One is that mental health is fundamental to health.

The qualities of mental health are essential to leading

a healthy life. Americans assign high priority to preventing disease and promoting personal well-being and

public health; so too must we assign priority to the task

of promoting mental health and preventing mental

disorders. Nonetheless, mental disorders occur and,

thus, treatment and mental health services are critical to

the Nation’s health. These emphases, combined with

research to increase the knowledge needed to treat and

prevent mental and behavioral disorders, constitute a

broad public health approach to an urgent health

concern.

A second message of the report is that mental

disorders are real health conditions that have an immense impact on individuals and families throughout

this Nation and the world. Appreciation of the clinically and economically devastating nature of mental disorders is part of a quiet scientific revolution that not

only has documented the extent of the problem, but in

recent years has generated many real solutions. The

decision to publish the report at this time was based, in

part, on the tremendous growth of the science base that

is enriching our understanding of the awe-inspiring

complexity of the brain and behavior. This understanding increasingly supports mental health practices.

The body of this report is a summary of an

extensive review of the scientific literature and of consultations with mental health care providers and consumers. Contributors guided by the Office of the

Surgeon General examined more than 3,000 research

articles and other materials, including first-person

accounts from individuals who have experienced

mental disorders. Today, a strong consensus among

Americans in all walks of life holds that our society no

longer can afford to view mental health as separate and

unequal to general health. This consensus resonates

with the Surgeon General’s conviction that mental

health should be part of the mainstream of health. 

The review of research supports two main findings:

& The efficacy of mental health treatments is well

documented, and

& A range of treatments exists for most mental

disorders.

On the strength of these findings, the single,

explicit recommendation of the report is to seek help if

you have a mental health problem or think you have

symptoms of a mental disorder.
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Once a person has made the decision to seek help

for a mental health problem, he or she can choose from

a broad variety of helping sources, treatment approaches, and service settings. There is no “one size fits

all” treatment for mental disorders. Personal preference

may influence, for example, the choice of psychotherapeutic, or “talk,” therapy over the use of medications; in another case, an individual may feel most

comfortable raising questions about symptoms of mental distress with a family doctor, with a trusted member

of the clergy, or, if a child’s health is the subject of

concern, with a teacher or a school counselor. There are

many individuals who are familiar with questions about

mental health care and who, as a first point of contact,

can provide invaluable assistance in obtaining appropriate and effective care.

Despite the efficacy of treatment options and the

many possible ways of obtaining a treatment of choice,

nearly half of all Americans who have a severe mental

illness do not seek treatment. Most often, reluctance to

seek care is an unfortunate outcome of very real

barriers. Foremost among these is the stigma that many

in our society attach to mental illness and to people

who have a mental illness. 

Stigma erodes confidence that mental disorders are

valid, treatable health conditions. It leads people to

avoid socializing, employing or working with, or

renting to or living near persons who have a mental

disorder, especially a severe disorder like schizophrenia. Stigma deters the public from wanting to pay for

care and, thus, reduces consumers’ access to resources

and opportunities for treatment and social services. A

consequent inability or failure to obtain treatment reinforces destructive patterns of low self-esteem, isolation, and hopelessness. Stigma tragically deprives

people of their dignity and interferes with their full

participation in society. It must be overcome. 

Increasingly effective treatments for mental

disorders promise to be the most effective antidote to

stigma. Effective interventions help people to understand that mental disorders are not character flaws but

are legitimate illnesses that respond to specific treatments, just as other health conditions respond to

medical interventions. Fresh approaches to disseminating research information are needed urgently.

While they are being developed, this report provides

information that organizations, experts, and many other

individuals can use to educate all Americans about

mental health and mental illness.

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Key themes, summarized here, run throughout the

report. The importance of information, policies, and

actions that will reduce and eventually eliminate the

cruel and unfair stigma attached to mental illness is

one. The importance of a solid research base for every

mental health and mental illness intervention is another.

As our Nation has seen in the past, establishing mental

health policy on the basis of good intentions alone can

make bad situations worse; evaluating the practicality

and effectiveness of new approaches is efficient and,

more critically, is accountable to those for whom an

intervention is intended. Additional themes of the

report include the following.

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In the United States, mental health programs, like

general health programs, are rooted in a populationbased public health model. Broader in focus than

medical models that concentrate on diagnosis and

treatment, public health attends, in addition, to the

health of a population in its entirety. A public health

approach encompasses a focus on epidemiologic

surveillance, health promotion, disease prevention, and

access to services. Although much more is known

through research about mental illness than about mental

health, the report attaches high importance to public

health practices that seek to identify risk factors for

mental health problems; to mount preventive interventions that may block the emergence of severe illnesses; and to actively promote good mental health. 

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The World Health Organization, in collaboration with

the World Bank and Harvard University, mounted an

ambitious research effort in the mid-1990s to determine
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the “burden of disability” associated with the whole

range of diseases and health conditions suffered by

peoples throughout the world. Possibly the most

striking finding of the landmark Global Burden of

Disease study is that the impact of mental illness on

overall health and productivity in the United States and

throughout the world is profoundly underrecognized.

Today, in established market economies such as the

United States, mental illness is the second leading

cause of disability and premature mortality. Mental

disorders collectively account for more than 15 percent

of the overall burden of disease from all causes and

slightly more than the burden associated with all forms

of cancer (Table 1). These data underscore the importance and urgency of treating and preventing mental

disorders and of promoting mental health in our

society. 

Table 1. Disease burden by selected illness

categories in established market economies,

1990

Percent of

Total DALYs*

All cardiovascular conditions 18.6

All mental illness** 15.4

All malignant disease (cancer) 15.0

All respiratory conditions 4.8

All alcohol use 4.7

All infectious and parasitic disease 2.8

All drug use 1.5

*Disability-adjusted life year (DALY) is a measure that

expresses years of life lost to premature death and years

lived with a disability of specified severity and duration

(Murray & Lopez, 1996).

**Disease burden associated with "mental illness" includes

suicide.

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As will be evident in the pages that follow, “mental

health” and “mental illness” may be thought of as

points on a continuum. Mental health refers to the

successful performance of mental function, resulting in

productive activities, fulfilling relationships with other

people, and the ability to adapt to change and to cope

with adversity. Mental health is indispensable to

personal well-being, family and interpersonal relationships, and contribution to community or society. It is

easy to overlook the value of mental health until

problems surface. Yet from early childhood until death,

mental health is the springboard of thinking and

communication skills, learning, emotional growth,

resilience, and self-esteem. These are the ingredients of

each individual’s successful contribution to community

and society. Americans are inundated with messages

about success—in school, in a profession, in parenting,

in relationships—without appreciating that successful

performance rests on a foundation of mental health.

Many ingredients of mental health may be

identifiable, but mental health is not easy to define. In

the words of a distinguished leader in the field of

mental health prevention, “. . . built into any definition

of wellness . . . are overt and covert expressions of

values. Because values differ across cultures as well as

among subgroups (and indeed individuals) within a

culture, the ideal of a uniformly acceptable definition

of the construct is illusory. . .” (Cowen, 1994). In other

words, what it means to be mentally healthy is subject

to many different interpretations that are rooted in

value judgments that may vary across cultures. The

challenge of defining mental health has stalled the

development of programs to foster mental health

(Secker, 1998), although some strides have been

made—for example, wellness programs for older

people.

Mental illness refers collectively to all diagnosable

mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking,

mood, or behavior (or some combination thereof)

associated with distress and/or impaired functioning.

Alzheimer’s disease exemplifies a mental disorder

largely marked by alterations in thinking (especially

forgetting). Depression exemplifies a mental disorder

largely marked by alterations in mood. Attentiondeficit/hyperactivity disorder exemplifies a mental

disorder largely marked by alterations in behavior

(overactivity) and/or thinking (inability to concentrate).

Alterations in thinking, mood, or behavior spawn a host

of problems— patient distress, impaired functioning, or
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heightened risk of death, pain, disability, or loss of

freedom (DSM-IV, 1994).

This report uses the term “mental health problems”

for signs and symptoms of insufficient intensity or

duration to meet the criteria for any mental disorder.

Almost everyone has experienced mental health

problems in which the distress one feels matches some

of the signs and symptoms of mental disorders. Mental

health problems may warrant active efforts in health

promotion, prevention, and treatment. Bereavement

symptoms in older adults offer a case in point. Bereavement symptoms of less than 2 months’ duration do not

qualify as a mental disorder, according to professional

manuals for diagnosis (DSM-IV, 1994). Nevertheless,

bereavement symptoms can be debilitating if they are

left unattended. They place older people at risk for depression, which, in turn, is linked to death from suicide,

heart attack, or other causes (Zisook & Shuchter, 1991,

1993; Frasure-Smith et al., 1993, 1995; Conwell,

1996). Much can be done—through formal treatment or

through support group participation—to ameliorate the

symptoms and to avert the consequences of bereavement. In this case, early intervention is needed to address a mental health problem before it becomes a

disorder. 

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As it examines mental health and illness in the United

States, the report confronts a profound obstacle to

public understanding, one that stems from an artificial,

centuries-old separation of mind and body.

Even today, everyday language encourages a

misperception that mental health or mental illness is

unrelated to physical health or physical illness. In fact,

the two are inseparable. In keeping with modern

scientific thinking, this report uses mind to refer to all

mental functions related to thinking, mood, and

purposive behavior. The mind is generally seen as

deriving from activities within the brain. Research reviewed for this report makes it clear that mental

functions are carried out by a particular organ, the

brain. Indeed, new and emerging technologies are

making it increasingly possible for researchers to

demonstrate the extent to which mental disorders and

their treatment—both with medication and with

psychotherapy—are reflected in physical changes in the

brain. 

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Chapter 1 of the report elaborates on the overarching

themes highlighted above and describes the criteria

applied to the scientific evidence that is cited throughout the report. The chapter also lists the key conclusions drawn from each succeeding chapter. These

conclusions are provided, as well, in the following

pages of this Executive Summary. 

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The past 25 years have been marked by several discrete, defining trends in the mental health field. These

have included:

& The extraordinary pace and productivity of

scientific research on the brain and behavior; 

& The introduction of a range of effective treatments

for most mental disorders;

& A dramatic transformation of our society’s

approaches to the organization and financing of

mental health care; and 

& The emergence of powerful consumer and family

movements.

Scientific Research. The brain has emerged as the

central focus for studies of mental health and mental

illness. New scientific disciplines, technologies, and

insights have begun to weave a seamless picture of the

way in which the brain mediates the influence of biological, psychological, and social factors on human

thought, behavior, and emotion in health and in illness.

Molecular and cellular biology and molecular genetics,

which are complemented by sophisticated cognitive and

behavioral science, are preeminent research disciplines

in the contemporary neuroscience of mental health.

These disciplines are affording unprecedented opportunities for “bottom-up” studies of the brain. This
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term refers to research that is examining the workings

of the brain at the most fundamental levels. Studies

focus, for example, on the complex neurochemical

activity that occurs within individual nerve cells, or

neurons, to process information; on the properties and

roles of proteins that are expressed, or produced, by a

person’s genes; and on the interaction of genes with

diverse environmental influences. All of these activities

now are understood, with increasing clarity, to underlie

learning, memory, the experience of emotion, and,

when these processes go awry, the occurrence of

mental illness or a mental health problem. 

Equally important to the mental health field is “topdown” research; here, as the term suggests, the aim is

to understand the broader behavioral context of the

brain’s cellular and molecular activity and to learn how

individual neurons work together in well-delineated

neural circuits to perform mental functions. 

Effective Treatments. As information accumulates

about the basic workings of the brain, it is the task of

translational research to transfer new knowledge into

clinically relevant questions and targets of research

opportunity—to discover, for example, what specific

properties of a neural circuit might make it receptive to

safer, more effective medications. To elaborate on this

example, theories derived from knowledge about basic

brain mechanisms are being wedded more closely to

brain imaging tools such as functional Magnetic

Resonance Imaging (MRI) that can observe actual brain

activity. Such a collaboration would permit investigators to monitor the specific protein molecules intended as the “targets” of a new medication to treat a

mental illness or, indeed, to determine how to optimize

the effect on the brain of the learning achieved through

psychotherapy.

In its entirety, the new “integrative neuroscience”

of mental health offers a way to circumvent the

antiquated split between the mind and the body that

historically has hampered mental health research. It

also makes it possible to examine scientifically many of

the important psychological and behavioral theories

regarding normal development and mental illness that

have been developed in years past. The unswerving

goal of mental health research is to develop and refine

clinical treatments as well as preventive interventions

that are based on an understanding of specific

mechanisms that can contribute to or lead to illness but

also can protect and enhance mental health.

Mental health clinical research encompasses

studies that involve human participants, conducted, for

example, to test the efficacy of a new treatment. A

noteworthy feature of contemporary clinical research is

the new emphasis being placed on studying the

effectiveness of interventions in actual practice settings. Information obtained from such studies increasingly provides the foundation for services research

concerned with the cost, cost-effectiveness, and “deliverability” of interventions and the design—including economic considerations—of service delivery

systems. 

Organization and Financing of Mental Health

Care. Another of the defining trends has been the transformation of the mental illness treatment and mental

health services landscapes, including increased reliance on primary health care and other human service

providers. Today, the U.S. mental health system is

multifaceted and complex, comprising the public and

private sectors, general health and specialty mental

health providers, and social services, housing, criminal

justice, and educational agencies. These agencies do

not always function in a coordinated manner. The configuration of the system reflects necessary responses to

a broad array of factors including reform movements,

financial incentives based on who pays for what kind of

services, and advances in care and treatment

technology. Although the hybrid system that exists

today serves diverse functions well for many people,

individuals with the most complex needs and the fewest

financial resources often find the system fragmented

and difficult to use. A challenge for the Nation in the

near-term future is to speed the transfer of new

evidence-based treatments and prevention interventions

into diverse service delivery settings and systems,

while ensuring greater coordination among these

settings and systems.

Consumer and Family Movements. The emergence

of vital consumer and family movements promises to

shape the direction and complexion of mental health
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programs for many years to come. Although divergent

in their historical origins and philosophy, organizations

representing consumers and family members have

promoted important, often overlapping, goals and have

invigorated the fields of research as well as treatment

and service delivery design. Among the principal goals

shared by much of the consumer movement are to

overcome stigma and prevent discrimination in policies

affecting persons with mental illness; to encourage selfhelp and a focus on recovery from mental illness; and

to draw attention to the special needs associated with a

particular disorder or disability as well as with age or

gender or by the racial and cultural identity of those

who have mental illness.

Chapter 2 of the report was written to provide

background information that would help persons from

outside the mental health field better understand topics

addressed in subsequent chapters of the report.

Although the chapter is meant to serve as a mental

health primer, its depth of discussion supports a range

of conclusions:

& The multifaceted complexity of the brain is fully

consistent with the fact that it supports all behavior and mental life. Proceeding from an

acknowledgment that all psychological experiences

are recorded ultimately in the brain and that all

psychological phenomena reflect biological processes, the modern neuroscience of mental health

offers an enriched understanding of the inseparability of human experience, brain, and mind.

& Mental functions, which are disturbed in mental

disorders, are mediated by the brain. In the process

of transforming human experience into physical

events, the brain undergoes changes in its cellular

structure and function. 

& Few lesions or physiologic abnormalities define the

mental disorders, and for the most part their causes

remain unknown. Mental disorders, instead, are

defined by signs, symptoms, and functional impairments.

& Diagnoses of mental disorders made using specific

criteria are as reliable as those for general medical

disorders. 

& About one in five Americans experiences a mental

disorder in the course of a year. Approximately 15

percent of all adults who have a mental disorder in

one year also experience a co-occurring substance

(alcohol or other drug) use disorder, which complicates treatment.

& A range of treatments of well-documented efficacy

exists for most mental disorders. Two broad types

of intervention include psychosocial treatments—

for example, psychotherapy or counseling—and

psychopharmacologic treatments; these often are

most effective when combined. 

& In the mental health field, progress in developing

preventive interventions has been slow because, for

most major mental disorders, there is insufficient

understanding about etiology (or causes of illness)

and/or there is an inability to alter the known etiology of a particular disorder. Still, some successful strategies have emerged in the absence of a

full understanding of etiology. 

& About 10 percent of the U.S. adult population use

mental health services in the health sector in any

year, with another 5 percent seeking such services

from social service agencies, schools, or religious

or self-help groups. Yet critical gaps exist between

those who need service and those who receive

service. 

& Gaps also exist between optimally effective

treatment and what many individuals receive in

actual practice settings.

& Mental illness and less severe mental health

problems must be understood in a social and

cultural context, and mental health services must

be designed and delivered in a manner that is

sensitive to the perspectives and needs of racial and

ethnic minorities. 

& The consumer movement has increased the involvement of individuals with mental disorders and

their families in mutual support services, consumer-run services, and advocacy. They are powerful

agents for changes in service programs and policy.

& The notion of recovery reflects renewed optimism

about the outcomes of mental illness, including that

achieved through an individual’s own self-care
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efforts, and the opportunities open to persons

with mental illness to participate to the full

extent of their interests in the community of

their choice. 

		
		

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The Surgeon General’s report takes a lifespan approach

to its consideration of mental health and mental illness.

Three chapters that address, respectively, the periods of

childhood and adolescence, adulthood, and later adult

life beginning somewhere between ages 55 and 65,

capture the contributions of research to the breadth,

depth, and vibrancy that characterize all facets of the

contemporary mental health field. 

The disorders featured in depth in Chapters 3, 4,

and 5 were selected on the basis of the frequency with

which they occur in our society, and the clinical,

societal, and economic burden associated with each. To

the extent that data permit, the report takes note of how

gender and culture, in addition to age, influence the

diagnosis, course, and treatment of mental illness. The

chapters also note the changing role of consumers and

families, with attention to informal support services

(i.e., unpaid services), with which many consumers are

comfortable and upon which they depend for

information. Persons with mental illness and, often,

their families welcome a proliferating array of support

services—such as self-help programs, family self-help,

crisis services, and advocacy—that help them cope

with the isolation, family disruption, and possible loss

of employment and housing that may accompany

mental disorders. Support services can help to dissipate

stigma and to guide patients into formal care as well.

Mental health and mental illness are dynamic, everchanging phenomena. At any given moment, a person’s

mental status reflects the sum total of that individual’s

genetic inheritance and life experiences. The brain

interacts with and responds—both in its function and in

its very structure—to multiple influences continuously,

across every stage of life. At different stages, variability in expression of mental health and mental illness

can be very subtle or very pronounced. As an example,

the symptoms of separation anxiety are normal in early

childhood but are signs of distress in later childhood

and beyond. It is all too common for people to

appreciate the impact of developmental processes in

children, yet not to extend that conceptual understanding to older people. In fact, people continue to

develop and change throughout life. Different stages of

life are associated with vulnerability to distinct forms

of mental and behavioral disorders but also with distinctive capacities for mental health. 

Even more than is true for adults, children must be

seen in the context of their social environments—that

is, family and peer group, as well as that of their larger

physical and cultural surroundings. Childhood mental

health is expressed in this context, as children proceed

along the arc of development. A great deal of contemporary research focuses on developmental processes, with the aim of understanding and predicting

the forces that will keep children and adolescents

mentally healthy and maintain them on course to

become mentally healthy adults. Research also focuses

on identifying what factors place some at risk for

mental illness and, yet again, what protects some

children but not others despite exposure to the same

risk factors. In addition to studies of normal development and of risk factors, much research focuses on

mental disorders in childhood and adolescence and

what can be done to prevent or treat these conditions

and on the design and operation of service settings best

suited to the needs of children. 

For about one in five Americans, adulthood—a

time for achieving productive vocations and for sustaining close relationships at home and in the

community—is interrupted by mental illness. Understanding why and how mental disorders occur in

adulthood, often with no apparent portents of illness in

earlier years, draws heavily on the full panoply of

research conducted under the aegis of the mental health

field. In years past, the onset, or occurrence, of mental

illness in the adult years was attributed principally to

observable phenomena—for example, the burden of

stresses associated with career or family, or the inheritance of a disease viewed to run in a particular

family. Such explanations now may appear naive at

best. Contemporary studies of the brain and behavior
0HQWDO +HDOWK $ 5HSRUW RI WKH 6XUJHRQ *HQHUDO



are racing to fill in the picture by elucidating specific

neurobiological and genetic mechanisms that are the

platform upon which a person’s life experiences can

either strengthen mental health or lead to mental

illness. It now is recognized that factors that influence

brain development prenatally may set the stage for a

vulnerability to illness that may lie dormant throughout

childhood and adolescence. Similarly, no single gene

has been found to be responsible for any specific

mental disorder; rather, variations in multiple genes

contribute to a disruption in healthy brain function that,

under certain environmental conditions, results in a

mental illness. Moreover, it is now recognized that

socioeconomic factors affect individuals’ vulnerability

to mental illness and mental health problems. Certain

demographic and economic groups are more likely than

others to experience mental health problems and some

mental disorders. Vulnerability alone may not be

sufficient to cause a mental disorder; rather, the causes

of most mental disorders lie in some combination of

genetic and environmental factors, which may be

biological or psychosocial.

The fact that many, if not most, people have

experienced mental health problems that mimic or even

match some of the symptoms of a diagnosable mental

disorder tends, ironically, to prompt many people to

underestimate the painful, disabling nature of severe

mental illness. In fact, schizophrenia, mood disorders

such as major depression and bipolar illness, and

anxiety often are devastating conditions. Yet relatively

few mental illnesses have an unremitting course

marked by the most acute manifestations of illness;

rather, for reasons that are not yet understood, the

symptoms associated with mental illness tend to wax

and wane. These patterns pose special challenges to the

implementation of treatment plans and the design of

service systems that are optimally responsive to an

individual’s needs during every phase of illness. As this

report concludes, enormous strides are being made in

diagnosis, treatment, and service delivery, placing the

productive and creative possibilities of adulthood

within the reach of persons who are encumbered by

mental disorders.

Late adulthood is when changes in health status

may become more noticeable and the ability to compensate for decrements may become limited. As the

brain ages, a person’s capacity for certain mental tasks

tends to diminish, even as changes in other mental activities prove to be positive and rewarding. Well into late

life, the ability to solve novel problems can be

enhanced through training in cognitive skills and problem-solving strategies. 

The promise of research on mental health promotion notwithstanding, a substantial minority of older

people are disabled, often severely, by mental disorders

including Alzheimer’s disease, major depression,

substance abuse, anxiety, and other conditions. In the

United States today, the highest rate of suicide—an alltoo-common consequence of unrecognized or inappropriately treated depression—is found in older males.

This fact underscores the urgency of ensuring that

health care provider training properly emphasizes skills

required to differentiate accurately the causes of cognitive, emotional, and behavioral symptoms that may,

in some instances, rise to the level of mental disorders,

and in other instances be expressions of unmet general

medical needs.

As the life expectancy of Americans continues to

extend, the sheer number—although not necessarily the

proportion—of persons experiencing mental disorders

of late life will expand, confronting our society with

unprecedented challenges in organizing, financing, and

delivering effective mental health services for this

population. An essential part of the needed societal

response will include recognizing and devising innovative ways of supporting the increasingly more

prominent role that families are assuming in caring for

older, mentally impaired and mentally ill family

members. 

*
1,'


& Childhood is characterized by periods of transition

and reorganization, making it critical to assess the

mental health of children and adolescents in the

context of familial, social, and cultural expectations about age-appropriate thoughts, emotions,

and behavior.
([HFXWLYH 6XPPDU\



& The range of what is considered “normal” is wide;

still, children and adolescents can and do develop

mental disorders that are more severe than the “ups

and downs” in the usual course of development. 

& Approximately one in five children and adolescents

experiences the signs and symptoms of a DSM-IV

disorder during the course of a year, but only about

5 percent of all children experience what professionals term “extreme functional impairment.”

& Mental disorders and mental health problems

appear in families of all social classes and of all

backgrounds. No one is immune. Yet there are

children who are at greatest risk by virtue of a

broad array of factors. These include physical

problems; intellectual disabilities (retardation); low

birth weight; family history of mental and addictive

disorders; multigenerational poverty; and caregiver separation or abuse and neglect.

& Preventive interventions have been shown to be

effective in reducing the impact of risk factors for

mental disorders and improving social and emotional development by providing, for example, educational programs for young children, parenteducation programs, and nurse home visits.

& A range of efficacious psychosocial and pharmacologic treatments exists for many mental disorders

in children, including attention-deficit/hyperactivity disorder, depression, and the disruptive

disorders.

& Research is under way to demonstrate the effectiveness of most treatments for children in

actual practice settings (as opposed to evidence of

“efficacy” in controlled research settings), and

significant barriers exist to receipt of treatment.

& Primary care and the schools are major settings for

the potential recognition of mental disorders in

children and adolescents, yet trained staff are

limited, as are options for referral to specialty care.

& The multiple problems associated with “serious

emotional disturbance” in children and adolescents

are best addressed with a “systems” approach in

which multiple service sectors work in an organized, collaborative way. Research on the effectiveness of systems of care shows positive

results for system outcomes and functional outcomes for children; however, the relationship

between changes at the system level and clinical

outcomes is still unclear. 

& Families have become essential partners in the

delivery of mental health services for children and

adolescents.

& Cultural differences exacerbate the general

problems of access to appropriate mental health

services. Culturally appropriate services have been

designed but are not widely available.

*
2,(	

& 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. 

& 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. 

& 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. 

& 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 ther-
0HQWDO +HDOWK $ 5HSRUW RI WKH 6XUJHRQ *HQHUDO



apies can be independent, combined, or

sequenced depending on the individual’s

diagnosis and per- sonal 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.

& Care and treatment in the real world of practice do

not conform to what research determines is best.

For many reasons, at times care is inadequate, but

there are models for improving treatment.

& 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.

& Sensitivity to culture, race, gender, disability,

poverty, and the need for consumer involvement

are important considerations for care and treatment.

& 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.

*
3,"
(	

& Important life tasks remain for individuals as they

age. Older individuals continue to learn and contribute to the society, in spite of physiologic changes due to aging and increasing health problems.

& Continued intellectual, social, and physical activity

throughout the life cycle are important for the

maintenance of mental health in late life. 

& Stressful life events, such as declining health and/

or the loss of mates, family members, or friends

often increase with age. However, persistent bereavement or serious depression is not “normal”

and should be treated. 

& Normal aging is not characterized by mental or

cognitive disorders. Mental or substance use disorders that present alone or co-occur should be

recognized and treated as illnesses. 

& Disability due to mental illness in individuals over

65 years old will become a major public health

problem in the near future because of demographic

changes. In particular, dementia, depression, and

schizophrenia, among other conditions, will all

present special problems in this age group:

— Dementia produces significant dependency and

is a leading contributor to the need for costly

long-term care in the last years of life;

— Depression contributes to the high rates of

suicide among males in this population; and 

— Schizophrenia continues to be disabling in

spite of recovery of function by some individuals in mid to late life. 

& There are effective interventions for most mental

disorders experienced by older persons (for example, depression and anxiety), and many mental

health problems, such as bereavement.

& Older individuals can benefit from the advances in

psychotherapy, medication, and other treatment interventions for mental disorders enjoyed by younger adults, when these interventions are modified for

age and health status.

& Treating older adults with mental disorders accrues

other benefits to overall health by improving the

interest and ability of individuals to care for themselves and follow their primary care provider’s

directions and advice, particularly about taking

medications.

& Primary care practitioners are a critical link in

identifying and addressing mental disorders in

older adults. Opportunities are missed to improve

mental health and general medical outcomes when

mental illness is underrecognized and undertreated

in primary care settings.

& Barriers to access exist in the organization and

financing of services for aging citizens. There are

specific problems with Medicare, Medicaid, nursing homes, and managed care. 

*
4,"

'5'''



&'	

In the United States in the late 20th century, researchbased capabilities to identify, treat, and, in some in-
([HFXWLYH 6XPPDU\



stances, prevent mental disorders are outpacing the

capacities of the existing service system to deliver

mental health care to all who would benefit from it.

Approximately 10 percent of children and adults

receive mental health services from mental health

specialists or general medical providers in a given year.

Approximately one in six adults, and one in five

children, obtain mental health services either from

health care providers, the clergy, social service agencies, or schools in a given year. 

Chapter 6 discusses the organization and financing

of mental health services. The chapter provides an

overview of the current system of mental health

services, describing where people get care and how

they use services. The chapter then presents information on the costs of care and trends in spending.

Only within recent decades, in the face of concerns

about discriminatory policies in mental health financing, have the dynamics of insurance financing become a significant issue in the mental health field. In

particular, policies that have emphasized cost containment have ushered in managed care. Intensive

research currently is addressing both positive and

adverse effects of managed care on access and quality,

generating information that will guard against untoward

consequences of aggressive cost-containment policies.

Inequities in insurance coverage for mental health and

general medical care—the product of decades of stigma

and discrimination—have prompted efforts to correct

them through legislation designed to produce financing

changes and create parity. Parity calls for equality

between mental health and other health coverage.

& Epidemiologic surveys indicate that one in five

Americans has a mental disorder in any one year.

& Fifteen percent of the adult population use some

form of mental health service during the year. Eight

percent have a mental disorder; 7 percent have a

mental health problem.

& Twenty-one percent of children ages 9 to 17

receive mental health services in a year.

& The U.S. mental health service system is complex

and connects many sectors (public–private,

specialty–general health, health–social welfare,

housing, criminal justice, and education). As a

result, care may become organizationally fragmented, creating barriers to access. The system is

also financed from many funding streams, adding

to the complexity, given sometimes competing

incentives between funding sources.

& In 1996, the direct treatment of mental disorders,

substance abuse, and Alzheimer’s disease cost the

Nation $99 billion; direct costs for mental

disorders alone totaled $69 billion. In 1990, indirect costs for mental disorders alone totaled $79

billion.

& Historically, financial barriers to mental health services have been attributable to a variety of economic forces and concerns (e.g., market failure,

adverse selection, moral hazard, and public provision). This has accounted for differential resource allocation rules for financing mental health

services. 

— “Parity” legislation has been a partial solution

to this set of problems.

— Implementing parity has resulted in negligible

cost increases where the care has been managed. 

& In recent years, managed care has begun to

introduce dramatic changes into the organization

and financing of health and mental health services.

& Trends indicate that in some segments of the

private sector per capita mental health expenditures have declined much faster than they

have for other conditions.

& There is little direct evidence of problems with

quality in well-implemented managed care programs. The risk for more impaired populations and

children remains a serious concern. 

& An array of quality monitoring and quality improvement mechanisms has been developed, although incentives for their full implementation

have yet to emerge. In addition, competition on the

basis of quality is only beginning in the managed

care industry.

& There is increasing concern about consumer

satisfaction and consumers’ rights. A Consumers

Bill of Rights has been developed and implemented

in Federal Employee Health Benefit Plans, with
0HQWDO +HDOWK $ 5HSRUW RI WKH 6XUJHRQ *HQHUDO



broader legislation currently pending in the

Congress.

*
6,'''.


','7%7'.		(	

In an era in which the confidentiality of all health care

information, its accessibility, and its uses are of concern to all Americans, privacy issues are keenly felt in

the mental health field. An assurance of confidentiality

is understandably critical in individual decisions to

seek mental health treatment. Although an extensive

legal framework governs confidentiality of consumerprovider interactions, potential problems exist and

loom ever larger. 

& People’s willingness to seek help is contingent on

their confidence that personal revelations of mental

distress will not be disclosed without their consent.

& The U.S. Supreme Court recently has upheld the

right to the privacy of these records and the

therapist-client relationship.

& Although confidentiality issues are common to

health care in general, there are special concerns

for mental health care and mental health care

records because of the extremely personal nature of

the material shared in treatment.

& State and Federal laws protect the confidentiality

of health care information but are often incomplete

because of numerous exceptions which often vary

from state to state. Several states have implemented

or proposed models for protecting privacy that may

serve as a guide to others.

& States, consumers, and family advocates take

differing positions on disclosure of mental health

information without consent to family caregivers.

In states that allow such disclosure, information

provided is usually limited to diagnosis, prognosis,

and information regarding treatment, specifically

medication. 

& When conducting mental health research, it is in

the interest of both the researcher and the individual participant to address informed consent and

to obtain certificates of confidentiality before proceeding. Federal regulations require informed consent for research being conducted with Federal

funds. 

& New approaches to managing care and information

technology threaten to further erode the confidentiality and trust deemed so essential between

the direct provider of mental health services and

the individual receiving those services. It is important to monitor advances so that confidentiality

of records is enhanced, instead of impinged upon,

by technology.

& Until the stigma associated with mental illnesses is

addressed, confidentiality of mental health information will continue to be a critical point of

concern for payers, providers, and consumers.

*
8,'	'
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9

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The extensive literature that the Surgeon General’s

report reviews and summarizes leads to the conclusion

that a range of treatments of documented efficacy

exists for most mental disorders. Moreover, a person

may choose a particular approach to suit his or her

needs and preferences. Based on this finding, the

report’s principal recommendation to the American

people is to seek help if you have a mental health

problem or think you have symptoms of a mental

disorder. As noted earlier, stigma interferes with the

willingness of many people—even those who have a

serious mental illness—to seek help. And, as documented in this report, those who do seek help will all

too frequently learn that there are substantial gaps in

the availability of state-of-the-art mental health services and barriers to their accessibility. Accordingly,

the final chapter of the report goes on to explore opportunities to overcome barriers to implementing the

recommendation and to have seeking help lead to effective treatment. 

The final chapter identifies the following courses

of action. 

& Continue to Build the Science Base: Today, integrative neuroscience and molecular genetics

present some of the most exciting basic research

opportunities in medical science. A plethora of new

pharmacologic agents and psychotherapies for

mental disorders afford new treatment oppor-
([HFXWLYH 6XPPDU\



tunities but also challenge the scientific

community to develop new approaches to

clinical and health services interventions

research. Because the vitality and feasibility of

clinical research hinges on the willing

participation of clinical research volunteers, it

is important for society to ensure that concerns

about protections for vulnerable research

subjects are addressed. Responding to the calls

of managed mental and behavioral health care

systems for evidence-based interventions will

have a much needed and discernible impact on

practice. Special effort is required to address

pronounced gaps in the mental health

knowledge base. Key among these are the

urgent need for evidence which supports

strategies for mental health promotion and

illness prevention. Additionally, research that

explores approaches for reducing risk factors

and strength- ening protective factors for the

prevention of men- tal illness should be

encouraged. As noted through- out the report,

high-quality research and the ef- fective

services it promotes are a potent weapon

against stigma.

& Overcome Stigma: Powerful and pervasive, stigma

prevents people from acknowledging their own

mental health problems, much less disclosing them

to others. For our Nation to reduce the burden of

mental illness, to improve access to care, and to

achieve urgently needed knowledge about the

brain, mind, and behavior, stigma must no longer

be tolerated. Research on brain and behavior that

continues to generate ever more effective treatments for mental illnesses is a potent antidote to

stigma. The issuance of this Surgeon General’s

Report on Mental Health seeks to help reduce

stigma by dispelling myths about mental illness, by

providing accurate knowledge to ensure more

informed consumers, and by encouraging help

seeking by individuals experiencing mental health

problems. 

& Improve Public Awareness of Effective Treatment: Americans are often unaware of the choices

they have for effective mental health treatments. In

fact, there exists a constellation of several

treatments of documented efficacy for most mental

disorders. Treatments fall mainly under several

broad categories—counseling, psychotherapy,

medication therapy, rehabilitation—yet within each

category are many more choices. All human

services professionals, not just health professionals, have an obligation to be better informed

about mental health treatment resources in their

communities and should encourage individuals to

seek help from any source in which they have

confidence.

& Ensure the Supply of Mental Health Services and

Providers: The fundamental components of effective service delivery, which include integrated

community-based services, continuity of providers

and treatments, family support services (including

psychoeducation), and culturally sensitive services,

are broadly agreed upon, yet certain of these and

other mental health services are in consistently

short supply, both regionally and, in some instances, nationally. Because the service system as

a whole, as opposed to treatment services considered in isolation, dictates the outcome of

recovery-oriented mental health care, it is

imperative to expand the supply of effective,

evidence-based services throughout the Nation.

Key personnel shortages include mental health

professionals serving children/adolescents and

older people with serious mental disorders and

specialists with expertise in cognitive-behavioral

therapy and interpersonal therapy, two forms of

psychotherapy that research has shown to be

effective for several severe mental disorders. For

adults and children with less severe conditions,

primary health care, the schools, and other human

services must be prepared to assess and, at times, to

treat individuals who come seeking help.

& Ensure Delivery of State-of-the-Art Treatments:

A wide variety of effective, community-based

services, carefully refined through years of

research, exist for even the most severe mental

illnesses yet are not being translated into community settings. Numerous explanations for the gap

between what is known from research and what is
0HQWDO +HDOWK $ 5HSRUW RI WKH 6XUJHRQ *HQHUDO



practiced beg for innovative strategies to

bridge it. 

& Tailor Treatment to Age, Gender, Race, and

Culture: Mental illness, no less than mental health,

is influenced by age, gender, race, and culture as

well as additional facets of diversity that can be

found within all of these population groups—for

example, physical disability or a person’s sexual

orientation. To be effective, the diagnosis and

treatment of mental illness must be tailored to all

characteristics that shape a person’s image and

identity. The consequences of not understanding

these influences can be profoundly deleterious.

“Culturally competent” services incorporate understanding of racial and ethnic groups, their histories,

traditions, beliefs, and value systems. With appropriate training and a fundamental respect for

clients, any mental health professional can provide

culturally competent services that reflect sensitivity

to individual differences and, at the same time,

assign validity to an individual’s group identity.

Nonetheless, the preference of many members of

ethnic and racial minority groups to be treated by

mental health professionals of similar background

underscores the need to redress the current

insufficient supply of mental health professionals

who are members of racial and ethnic minority

groups.

& Facilitate Entry Into Treatment: Public and

private agencies have an obligation to facilitate

entry into mental health care and treatment through

the multiple “portals of entry” that exist: primary

health care, schools, and the child welfare system.

To enhance adherence to treatment, agencies

should offer services that are responsive to the

needs and preferences of service users and their

families. At the same time, some agencies receive

inappropriate referrals. For example, an alarming

number of children and adults with mental illness

are in the criminal justice system inappropriately.

Importantly, assuring the small number of individuals with severe mental disorders who pose a

threat of danger to themselves or others ready access to adequate and appropriate services promises

to reduce significantly the need for coercion in the

form of involuntary commitment to a hospital

and/or certain outpatient treatment requirements

that have been legislated in most states and territories. Coercion should not be a substitute for

effective care that is sought voluntarily; consensus

on this point testifies to the need for research designed to enhance adherence to treatment.

& Reduce Financial Barriers to Treatment: Concerns about the cost of care—concerns made worse

by the disparity in insurance coverage for mental

disorders in contrast to other illnesses—are among

the foremost reasons why people do not seek

needed mental health care. While both access to

and use of mental health services increase when

benefits for those services are enhanced, preliminary data show that the effectiveness—and,

thus, the value—of mental health care also has

increased in recent years, while expenditures for

services, under managed care, have fallen. Equality

between mental health coverage and other health

coverage—a concept known as parity—is an

affordable and effective objective. 

*&

 *


This report is comprehensive but not exhaustive in its

coverage of mental health and mental illness. It

considers mental health facets of some conditions

which are not always associated with the mental

disorders and does not consider all conditions which

can be found in classifications of mental disorders such

as DSM-IV. The report includes, for example, a

discussion of autism in Chapter 3 and provides an

extensive section on Alzheimer’s disease in Chapter 5.

Although DSM-IV lists specific mental disorder criteria

for both of these conditions, they often are viewed as

being outside the scope of the mental health field. In

both cases, mental health professionals are involved in

the diagnosis and treatment of these conditions, often

characterized by cognitive and behavioral impairments.

Developmental disabilities and mental retardation are

not discussed except in passing in this report. These

conditions were considered to be beyond its scope with

a care system all their own and very special needs. The

same is generally true for the addictive disorders, such

as alcohol and other drug use disorders. The latter,
([HFXWLYH 6XPPDU\



however, co-occur with such frequency with the other

mental disorders, which are the focus of this report, that

the co-occurrence is discussed throughout. The report

addresses the epidemiology of addictive disorders and

their co-occurrence with other mental disorders as well

as the treatment of co-occurring conditions. Brief

sections on substance abuse in adolescence and late life

also are included in the report.


*
' *


In September 1997, the Office of the Surgeon General,

with the approval of the Secretary of the Department of

Health and Human Services, authorized the Substance

Abuse and Mental Health Services Administration

(SAMHSA) to serve as lead operating division for

preparing the Surgeon General’s Report on Mental

Health. SAMHSA’s Center for Mental Health Services

worked in partnership with the National Institute of

Mental Health, National Institutes of Health, to develop

this report under the guidance of Surgeon General

David Satcher, M.D., Ph.D. The Federal partners

established a Planning Board comprising individuals

who represent a broad range of expertise in mental

health: university-based researchers and educators,

practicing mental health professionals, self-identified

consumers of mental health services, and many

knowledgeable advocates in diverse areas of the mental

health field. Also included on the Planning Board were

individuals representing Federal Operating Divisions,

Offices, Centers, and Institutes and private nonprofit

foundations with interests in the area of mental health.

'
	

Howard H. Goldman, M.D., Ph.D., Senior Scientific Editor,

Professor of Psychiatry, University of Maryland School of

Medicine, Baltimore, Maryland.

CAPT Patricia Rye, J.D., M.S.W., Managing Editor, Office

of the Director, Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Paul Sirovatka, M.S., Coordinating Editor, Science Writer,

Office of Science Policy and Program Planning, National

Institute of Mental Health, National Institutes of Health,

Bethesda, Maryland.

'
':
'


Miriam Davis, Ph.D., Medical Writer and Consultant, Silver

Spring, Maryland.

 
	

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Zisook, S., & Shuchter, S. R. (1991). Depression through the

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