In the 16th in a series of assessments of Healthy People
2010, Acting Assistant Secretary for Health Cristina Beato
chaired a focus area Progress Review on Mental Health and Mental
Disorders. Dr. Beato noted that President George W. Bush has made
mental health a priority of his administration, as evidenced by
the establishment of the New Freedom Commission on Mental Health.
The recommendations of the Commission’s Final Report, as well as
the National Strategy for Suicide Prevention and other programs
of the U.S. Department of Health and Human Services (HHS), will
contribute to the transformation of the mental healthcare system
and to the advancement of mental health as a vital component of
the overall health and well-being of the nation. In conducting the
review, Dr. Beato was assisted by staff of the Substance Abuse and
Mental Health Services Administration (SAMHSA) and the National
Institutes of Health, the co-lead agencies for this Healthy
People 2010 focus area. Also participating were representatives
of other HHS offices and agencies.
Charles Curie, Administrator of SAMHSA, expanded on Dr. Beato’s
remarks about the New Freedom Commission by outlining SAMHSA’s plans
to take transformative steps to improve the nation’s mental healthcare
system in line with the 6 goals and 19 recommendations contained
in the Commission’s Report. The President and HHS Secretary Tommy
G. Thompson had charged SAMHSA with assessing the Commission’s recommendations
and delineating the role of the Federal Government. Many of the
report’s goals and recommendations correspond closely with objectives
of Healthy People 2010 (e.g., to prevent suicide and to
increase employment of people who have mental illness). SAMHSA is
already working with other Federal agencies in a synergistic approach
to providing state partners with the flexibility and incentives
needed to exert the full force of resources available for improving
the lives of people with mental disorders.
The complete text for the Mental Health and Mental Disorders focus
area of Healthy People 2010 is available at www.healthypeople.gov/document/html/volume2/18mental.htm.
The meeting agenda, data presentation (tables and charts), and other
materials for the Progress Review can be found at www.cdc.gov/nchs/about/otheract/
hpdata2010/focusareas/fa18-mentalhealth.htm.
Data Trends
Edward Sondik, Director of the National Center for Health Statistics,
presented an overview of data that define the status of selected
objectives in this focus area. Indicating the magnitude of mental
health-related issues, Dr. Sondik noted that mental illness ranks
first among illnesses that cause disability in the United States,
Canada, and Western Europe. Of $1 trillion spent on health care
in the United States in 1997, $71 billion went toward the direct
costs of treating mental illness. Dr. Sondik devoted particular
attention to five Healthy People 2010 objectives: two that
are indicators of mental health status, one that concerns the expansion
of resources for treatment, and two that relate to state activities.
In 2001, the age-adjusted rate of suicide for the total population
was 10.7 per 100,000, a slight increase from the 1999 rate of 10.5.
In terms of gender, males died by suicide at roughly 4½
times the rate of females in 2001 (18.1 compared with 4.0 per 100,000).
Among males, firearms were the leading suicide modality in 2001
for all age cohorts for whom data were available, except those from
10 to 14 years of age. In that age group, among whom suicide is
the third leading cause of death, suffocation was the predominant
modality for both males and females. Firearms accounted for less
than 40 percent of suicides in all age cohorts of females, whereas
poisoning accounted for a much larger proportion of female suicides
at all life stages above 10 years of age than it did for comparable
age cohorts of males. Of five racial and ethnic groups, non-Hispanic
whites had the highest rate of suicide in 2001 (12.5 per 100,000,
age-adjusted), followed by American Indians/Alaska Natives at 10.6
per 100,000. Asians/Pacific Islanders, Hispanics, and blacks had
rates less than 6 per 100,000 in 2001. Among people 15 to 17 years
of age, American Indians/Alaska Natives died by suicide in 2001
at a rate of more than 14 per 100,000, which is more than twice
the rate for the total population in that age group. The highest
rates of suicide in 2001 (13.0 to 19.8 per 100,000) generally occurred
in the western mountain states, Alaska, and Florida. The 2010 target
rate for suicide is 5.0 per 100,000 (Obj. 18-1).
Suicide attempts are more common than suicide deaths. According
to a 2001 survey of students in grades 9 through 12, 2.6 percent
reported a suicide attempt in the preceding year that required medical
attention. The rate for female students (3.1 percent) was about
50 percent higher than that for male students (2.1 percent). By
gender, race, and ethnicity, the highest rate of suicide attempts
was recorded for Hispanic females, the second highest for black
males. The target is 1.0 percent (Obj. 18-2). Major depression is
associated with suicide attempts. Data collected during the period
1988–1994 show that women in the age group 17 to 39 years
reported having experienced at least one major episode of depression
at a rate of 11.2 percent, almost twice the rate (6 percent) of
men in the same cohort.
In 1998, 64 percent of juvenile justice facilities screened new
admissions for mental health problems. A target has yet to be set
for the objective (18-8) to increase the proportion of such facilities
that do so. In preliminary data for 2003, 39 states and the District
of Columbia reported tracking consumers’ satisfaction with
the mental health services they receive, up from 36 entities in
1999. The target is 51 (Obj. 18-12). In 2002–2003, 21 states
and the District of Columbia reported having an operational mental
health plan that addresses mental health crisis interventions, ongoing
screening, and treatment services for older people, a decrease from
the 24 entities that had such a plan in 1997. The target is 51 (Obj.
18-14).
Key Challenges and Current Strategies
In the presentations that followed the discussion of data, the
principal discussants were Thomas Insel, Director of NIH’s
National Institute of Mental Health (NIMH), and Kathryn Power, Director
of SAMHSA’s Center for Mental Health Services. Participants
in the review identified a number of obstacles to achieving the
objectives and discussed activities under way to meet these challenges,
including the following:
- Until now, the major points of contact with people who have mental
illness have too often consisted of homeless shelters, the criminal
justice system, and the welfare system, thus depriving many individuals
with mental disorders of the opportunity for diagnosis and treatment.
- About 30,000 deaths from suicide are said to occur each
year in the United States, and this figure may seriously underestimate
the actual total.
- Suicide deaths are undercounted for many reasons, including
the stigma attached to suicide and the variable standards of training
and performance for coroners and medical examiners who complete
death certificates.
- In the United States and other industrialized nations, about
90 percent of suicides are associated with mental illness, including
alcohol and substance abuse disorders.
- The risk for suicide goes up as immigrant groups become
more acculturated in the United States, possibly reflecting the
erosion of familial protective factors accompanied by an increasing
intensity of cultural clashes.
- CDC efforts to expand the National Violent Death Reporting
System beyond the current 13 states may appear to increase rates
of suicide because of more accurate classification of deaths that
would have been misclassified previously.
- SAMHSA is creating a public/private alliance to oversee
and govern the National Strategy for Suicide Prevention and is funding
a national suicide prevention resource center.
- In fiscal year (FY) 2003, NIMH support for suicide research
totaled about $26 million, an amount that will increase in FY 2004
with the funding of several developing centers on interventions
for suicide prevention. Most suicide prevention research has focused
on treating people at high risk for suicide (i.e., those with a
mental disorder who have made a recent suicide attempt). Approximately
40 percent of people who die by suicide have made a prior suicide
attempt.
- SAMHSA is working with the National Association of State
Mental Health Program Directors to develop a Uniform Reporting System
(URS) so that all states will be able to use common measures and
definitions in providing consistent mental health data that can
be aggregated into a national database. The URS will include data
for children in age groups from 0 to 3, 4 to 12, and 13 to 17 years.
Heretofore, national surveys have not covered children younger than
12 years.
- Bipolar disorder, schizophrenia, depression, and autism,
among other mental disorders, are characterized in part by distinctive
organic changes in the brain. Research in this area may open new
pathways to treatment and prevention.
- In the past two decades, new medications have been developed,
such as SSRIs (selective serotonin re-uptake inhibitors) for depression
and atypical antipsychotics for schizophrenia. These medications
control many of the more troubling symptoms of mental illnesses.
Approaches for Consideration
During the review, the following suggestions were made for steps
to bring about further progress toward achievement of the objectives:
- Increase research on both the risk-enhancing and the protective
effects of culture in regard to suicide rates among racial and ethnic
groups, including the testing of interventions to reduce both depression
and proneness to suicide.
- Focus more intently on suicide prevention interventions
among population groups at highest risk (e.g., older white males,
70 percent of whom had seen a physician within 1 month of committing
suicide).
- Provide incentives for physicians to make mental health
assessment a routine part of their physical examinations of patients.
- Explore new approaches in the provision of mental health
services, applying lessons learned and successful models from other
fields of health care.
- Ensure that cultural competency on the part of providers
is incorporated into mental health service programs at all levels.
- Give greater attention to the role of spirituality as a
component of mental health.
- Seek greater understanding of the long-term effects of medications
prescribed to young children.
- To reduce the perceived stigma associated with mental disorders,
encourage wider use of group practice settings that include the
provision of both physical and mental health services.
- Strive to improve coordination across primary health care
and mental health care systems for the greater benefit of the patients
served.
Contacts for information about Healthy People 2010
focus area 18—Mental Health and Mental Disorders:
- Substance Abuse and Mental Health Services Administration—Nancy
Brady, nbrady@samhsa.gov
- Office of Disease Prevention and Health Promotion (coordinator
of the Progress Reviews)—Sue Martone (liaison to the focus
area 18 workgroup), smartone@osophs.dhhs.gov
|
Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
Back to Top
|