Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 1
Overview of the Report's Chapters
The preceding sections have addressed overarching themes in the body of the
report. This section provides a brief overview of the entire report, including a
description of its general orientation and a summary of key conclusions drawn
from each chapter.
Chapter 2 begins with an overview of research under way today that is focused on
the brain and behavior in mental health and mental illness. It explains how
newer approaches to neuroscience are mending the mind-body split, which for so
long has been a stumbling block to understanding the relationship of the brain
to behavior, thought, and emotion. Modern integrative neuroscience offers a
means of linking research on broad “systems-level” aspects of brain function
with the remarkably detailed tools and findings of molecular genetics. There
follows an overview of mental illness that highlights topics including symptoms,
diagnosis, epidemiology (i.e., research having to do with the distribution and
determinants of mental disorders in population groups), and cost, all of which
are discussed in the context of specific disorders throughout the report. The
section on etiology reviews research that is seeking to define, with ever
greater precision, the causes of mental illnesses. As will be seen, etiology
research must examine fundamental biological and behavioral processes, as well
as a necessarily broad array of life events. No less than research on normal
healthy development, etiological research underscores the inextricability of
nature and nurture, or biological and psychosocial influences, in mental
illness. The section on development of temperament reveals how mental health
research has attempted over much of the past century to understand how
biological, psychological, and sociocultural factors meld in health as well as
illness. The chapter then reviews research approaches to the prevention and
treatment of mental disorders and provides an overview of mental health services
and their delivery. Final sections cover the growing influence on the mental
health field of cultural diversity, the importance of consumerism, and new
optimism about recovery from mental illness.
Chapters 3, 4, and 5 capture the breadth, depth, and vibrancy of the mental
health field. The chapters probe mental health and mental illness in children
and adolescents, in adulthood (i.e., in persons up to ages 55 to 65), and in
older adults, respectively. This life span approach reflects awareness that
mental health, and the brain and behavioral disorders that impinge upon it, are
dynamic, ever-changing phenomena that, at any given moment, reflect the sum
total of every person’s genetic inheritance and life experiences. The brain is
extraordinarily “plastic,” or malleable. It interacts with and responds—both in
its function and in its very structure—to multiple influences continuously,
across every stage of life. Variability in expression of mental health and
mental illness over the life span 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, older people
continue to develop and change. Different stages of life are associated with
distinct forms of mental and behavioral disorders and with distinctive
capacities for mental health.
With rare exceptions, few persons are destined to a life marked by unremitting,
acute mental illness. The most severe, persistent forms of mental illness tend
to be amenable to treatment, even when recurrent and episodic. As conditions wax
and wane, opportunities exist for interventions. The goal of an intervention at
any given time may vary. The focus may be on recovery, prevention of recurrence,
or the acquisition of knowledge or skills that permit more effective management
of an illness. Chapters 3 through 5 cover a uniform list of topics most relevant
to each age cluster. Topics include mental health; prevention, diagnosis, and
treatment of mental illness; service delivery; and other services and supports.
It would be impractical for a report of this type to attempt to address every
domain of mental health and mental illness; therefore, this report casts a
spotlight on selected topics in each of Chapters 3 through 5. The various
disorders featured in depth in a given chapter were selected on the basis of
their prevalence 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 patients are so comfortable (Phelan et al., 1997) and upon which they
depend for information. Patients and 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 dissipate stigma and guide patients into formal care
as well.
Although the chapters that address stages of development afford a sense of the
breadth of issues pertinent to mental health and illness, the report is not
exhaustive. The neglect of any given disorder, population, or topic should not
be construed as signifying a lack of importance.
Chapter 6 discusses the organization and financing of mental health services.
The first section 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 have the dynamics of insurance financing become a
significant issue in the mental health field; these are discussed, as is the
advent of managed care. The chapter addresses both positive and adverse effects
of managed care on access and quality and describes efforts to guard against
untoward consequences of aggressive cost-containment policies. The final section
documents some of the inequities between general health care and mental health
care and describes efforts to correct them through legislative regulation and
financing changes.
The confidentiality of all health care information has emerged as a core issue
in recent years, as concerns regarding the accessibility of health care
information and its uses have risen. As Chapter 7 illustrates, privacy concerns
are particularly keenly felt in the mental health field, beginning with the
importance of an assurance of confidentiality in individual decisions to seek
mental health treatment. The chapter reviews the legal framework governing
confidentiality and potential problems with that framework, and policy issues
that must be addressed by those concerned with the confidentiality of mental
health and substance abuse information.
Chapter 8 concludes, on the basis of the extensive literature that the Surgeon
General’s report reviews and summarizes, that the efficacy of mental health
treatment is well-documented. Moreover, there exists a range of treatments from
which people may choose a particular approach to suit their 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 mental illness. The chapter explores opportunities to overcome
barriers to implementing the recommendation and to have seeking help lead to
effective treatment.
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