Chapter 1
Introduction and Themes

Overarching Themes

The Science Base of the Report

Overview of the Report’s Chapters

Chapter Conclusions

Preparation of the Report


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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