Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 2
Mental Health and Mental Illness Across the Lifespan
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, ever-changing 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 experienced by
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 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 all-too-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.
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