Chapter 4
Adults and Mental Health

Chapter Overview

Anxiety Disorders

Mood Disorders

Schizophrenia

Service Delivery

Other Services And Supports

Conclusions

References

Chapter 4
Adults and Mental Health

Adulthood is a time for achieving productive vocations and for sustaining close relationships at home and in the community. These aspirations are readily attainable for adults who are mentally healthy. And they are within reach for adults who have mental disorders, thanks to major strides in diagnosis, treatment, and service delivery.

This chapter reviews the current state of knowledge about mental health in adults, along with selected mental disorders: anxiety disorders, mood disorders, and schizophrenia. These disorders are highlighted largely because of their prevalence in the population and the burden of illness associated with each. The chapter then turns to service delivery, describing the effective organization and range of services for adults with the most severe mental disorders. It also reviews an array of other services and supports designed to provide comprehensive care beyond the formal therapeutic setting.

Chapter Overview

Mental health in adulthood is characterized by the successful performance of mental function, enabling individuals to cope with adversity and to flourish in their education, vocation, and personal relationships. These are the areas of functioning most widely recognized by the mental health field. Yet, from the perspective of different cultures, these measures may define the concept of mental health too narrowly. As noted in Chapter 2, many groups, particularly ethnic and racial minority group members, also emphasize community, spiritual, and religious ties as necessary for mental health. The mental health profession is becoming more aware of the importance of reaching out to other cultures; an innovation termed “linguistically and culturally competent services” is pertinent both to the field’s conception of mental health and to the diagnosis and treatment of mental disorders.

An assortment of traits or personal characteristics have been viewed as contributing to mental health, including self-esteem, optimism, and resilience (Alloy & Abramson, 1988; Seligman, 1991; Institute of Medicine [IOM], 1994; Beardslee & Vaillant, 1997). These and related traits are seen as sources of personal resilience needed to weather the storms of stressful life events.

Stressful life events in adulthood include the breakup of intimate romantic relationships, death of a family member or friend, economic hardship, role conflict, work overload, racism and discrimination, poor physical health, accidental injuries, and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Stressful life events in adulthood also may reflect past events. Severe trauma in childhood, including sexual and physical abuse, may persist as a stressor into adulthood, or may make the individual more vulnerable to ongoing stresses (Browne & Finkelhor, 1986). Although some kinds of stressful life events are encountered almost universally, certain demographic groups have greater exposure and/or vulnerability to their cumulative impact. These groups include women, younger adults, unmarried adults, African Americans, and individuals of lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).

Anxiety disorders are the most prevalent mental disorders in adults (Regier et al., 1990). The anxiety disorders affect twice as many women as men. A broad category, anxiety disorders include panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder, among others. Underlying this heterogeneous group of disorders is a state of heightened arousal or fear in relation to stressful events or feelings. The biological manifestations of anxiety, which are grounded in the “fight-or-flight” response, are unmistakable: they include surge in heart rate, sweating, and tensing of muscles. But this is certainly not the whole picture. Although the full array of biological causes and correlates of anxiety are not yet in our grasp, numerous effective treatments for anxiety disorders exist now. Treatment draws on an assortment of psychosocial and pharmacological approaches, administered alone or in combination.

Mood disorders take a monumental toll in human suffering, lost productivity, and suicide. Moreover, when unrecognized, they can result in unnecessary health care use. Mood disorders rank among the top 10 causes of worldwide disability (Murray & Lopez, 1996). Major depression and bipolar disorder are the most familiar mood disorders, but there are others including cyclothymia (alternating manic and depressive states that, while protracted, do not meet criteria for bipolar disorder) and dysthymia (a chronic, albeit symptomatically milder form of depression). The causes of mood disorders are not fully known. They may be triggered by stressful life events and enduring stressful social conditions (e.g., poverty and discrimination). With the exception of bipolar disorder, they too, like the anxiety disorders, are twice as common in women as men. One subtype of mood disorder, seasonal affective disorder, in which episodes of depression tend to occur in the late fall and winter, is seven times more common in women than in men (Blumenthal, 1988). Many psychosocial and genetic factors interact to dictate the appearance and persistence of mood disorders, according to the biopsychosocial model presented in Chapter 2.

Mood disorders, like anxiety disorders, can be treated with a host of effective pharmacological and psychosocial treatments. Either type of treatment is effective for about 50 to 70 percent of patients in outpatient settings (Depression Guideline Panel, 1993). Severe depression seems to resolve more quickly with pharmacotherapy (Depression Guideline Panel, 1993) and may be helped further by multimodal therapy (the combination of pharmacotherapy and psychotherapy) (Thase et al., 1997b). Despite the efficacy of treatment, a surprising fraction of those with mood disorders go untreated (Katon et al., 1992; Narrow et al., 1993; Wells et al., 1994; Thase, 1996). The foremost barriers to treatment include cost, stigma, and problems in the organization of service systems that contribute to the underrecognition of these disorders.

Schizophrenia affects about 1 percent of the population, yet its severity and persistence reverberate throughout the mental health service system. Schizophrenia is marked by profound alterations in cognition and emotion. Symptoms frequently include hearing internal voices or experiencing other sensations not connected to an obvious source (hallucinations) and assigning unusual significance or meaning to normal events or holding false personal beliefs (delusions). The course of illness in schizophrenia is quite variable, with most people having periods of exacerbation and remission. Schizophrenia had once been thought to have a uniformly downhill course, but recent research dispels this view. Long-term followup studies show that many individuals with schizophrenia significantly improve and some recover (Ciompi, 1980; Harding et al., 1992). Although the causes of schizophrenia are not fully known, research points to the prominent role of genetic factors and to the impact of adverse environmental influences during early brain development (Tsuang et al., 1991; Weinberger & Lipska, 1995; Andreasen, 1997b). New pharmacological treatments are at least as effective as past pharmacological treatments with fewer troubling side effects.

Effective treatment of schizophrenia extends well beyond pharmacological therapy: it also includes psychosocial interventions, family interventions, and vocational and psychosocial rehabilitation. For those patients who are high service users, treatment should be coordinated by an interdisciplinary team that provides high-intensity, community-based services (Lehman & Steinwachs, 1998a). The prototype for this intensive case-management approach, which is useful for persons with other severe and persistent mental disorders as well, is assertive community treatment, described more thoroughly later in this chapter. Among the services included in this approach is substance abuse treatment. Its inclusion stems from findings that about half of patients with serious mental disorders (including schizophrenia) develop alcohol or other drug abuse problems (Drake & Osher, 1997). Even though research generated a range of recommendations for effective treatment of schizophrenia, it is alarming that less than 50 percent of patients actually receive many of the recommended treatments and that the gap was more pronounced in African Americans (Lehman & Steinwachs, 1998b).

The social consequences of serious mental disorders—family disruption, loss of employment and housing—can be calamitous. Comprehensive treatment, which includes services that exist outside the formal treatment system, is crucial to ameliorate symptoms, assist recovery, and, to the extent that these efforts are successful, redress stigma. Consumer self-help programs, family self-help, advocacy, and services for housing and vocational assistance complement and supplement the formal treatment system. Many of these services are operated by consumers, that is, people who use mental health services themselves. The logic behind their leadership in delivery of these services is that consumers are thought to be capable of engaging others with mental disorders, serving as role models, and increasing the sensitivity of service systems to the needs of people with mental disorders (Mowbray et al., 1996).

Mental Health in Adulthood

What constitutes mental health during the adult years? A widely used standard of mental health is the absence of a defined mental disorder. This standard has its limitations (discussed later), yet remains useful for epidemiological purposes. Epidemiology studies investigate the prevalence of mental disorders within several time frames: current, the past 12 months, and across a lifetime. Two well-designed national epidemiologic surveys estimate that about 80 percent of the adult population of the United States do not have a mental disorder during a year and hence may be considered “mentally healthy” (i.e., absence of a mental disorder) during any given year (Regier et al., 1993; Kessler et al., 1994). Thus, the popular notion that everyone is “dysfunctional” is far from the truth (Table 4-1). Yet, from time to time, many adults experience mental health problems.

Defining mental health by the absence of mental disorder does not convey the full picture of mental health. Among its limitations, this definition excludes adults with mental disorders who function well between episodes of illness. These people often are considered by themselves, and by coworkers, friends, and families, to be “mentally healthy” in spite of a history of mental illness and the risk of recurrence.

In addition to the mental health criteria cited earlier—that is, the successful performance of mental function, enabling individuals to cope with adversity and to flourish in their education, vocation, and personal relationships—a complementary approach defines the positive features of mental health in terms of attaining developmental milestones of adulthood, or in terms of displaying selected personality characteristics, traits, or attributes. Developmental theorist Erik Erikson viewed mental health in adulthood as achieving developmental tasks or milestones. According to Erikson’s formulation and his subsequent empirical research on adult men, adulthood was the time for overcoming what he termed “psychosocial crises,” the resolution of which led to satisfactory interpersonal and sexual relationships and to the pursuit of broader concerns for society and future generations (Erikson, 1963; Vaillant, 1977). However, these milestones, and the developmental theories that underpin them, have been criticized as reflecting the norms of European males rather than of women and other cultures.

Personality Traits
Mental health and mental illness can be seen as the product of various personality traits, behavior patterns, and other characteristics which have roots in the individual’s prior life experiences or biology.

Table 4-1. Best estimate 1-year prevalence based on ECV and NCS, ages 18-54

ECA Prevalence (%)
NCS Prevalence (%)
Best Estimate ** (%)
Any Anxiety Disorder
13.1
18.7
16.4
Simple Phobia
8.3
8.6
8.3
Social Phobia
2.0
7.4
2.0
Agoraphobia
4.9
3.7
4.9
GAD
(1.5)*
3.4
3.4
Panic Disorder
1.6
2.2
1.6
OCD
2.4
(0.9)*
2.4
PTSD
(1.9)*
3.6
3.6
Any Mood Disorder
7.1
11.1
7.1
MD Episode
6.5
10.1
6.5
Unipolar MD
5.3
8.9
5.3
Dysthymia
1.6
2.5
1.6
Biopolar I
1.1
1.3
1.1
Biopolar II
0.6
0.2
0.6
Schizophrenia 1.3
1.3
Nonaffective Psychosis 0.2
0.2
Somatization 0.2
0.2
ASP 2.1
2.1
Anorexia Nervosa 0.1
0.1
Severe Cognitive Impairment
1.2
1.2
Any Disorder
19.5
23.4
21.0

*Numbers in parentheses indicate the prevalence of the disorder without any comorbidity. These rates were calculated using the NCS data for GAD and PTSD, and the ECA data for OCD. The rates were not used in calculating the any anxiety disorder and any disorder totals for the ECA and NCS columns. The unduplicated GAD and PTSD rates were added to the best estimate total for any anxiety disorder (3.3%) and any disorder (1.5%).

**In developing best-estimate 1-year prevalence rates from the two studies, a conservative procedure was followed that had previously been used in an independent scientific analysis comparing these two data sets (Andrews, 1995). For any mood disorder and any anxiety disorder, the lower estimate of the two surveys was selected, which for these data was the ECA. The best estimate rates for the individual mood and anxiety disorders were then chosen from the ECA only, in order to maintain the relationships between the individual disorders. For other disorders that were not covered in both surveys, the available estimate was used.

Key to abbreviations: ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study; GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; MD, major depression; ASP, antisocial personality disorder.

Source: D. Regier, W. Narrow, & D. Rae, personal communication, 1999

Personality traits are thought to confer either beneficial or detrimental effects on mental health during adulthood. Here too, however, there may be insufficient attention to gender and culture. The culture-bound nature of much of behavior has limited widespread predictive validity of personality research. (Mischel & Shoda, 1968). With this caveat in mind, a brief summary of healthy and maladaptive characteristics follows.

Self-Esteem
Self-esteem refers to an abiding set of beliefs about one’s own worth, competence, and abilities to relate to others (Vaughan & Oldham, 1997). Self-esteem also has been conceptualized as buffering the individual from adverse life events. Emotional well-being is often associated with a slightly positive, yet realistic, outlook (Alloy & Abramson, 1988). The opposite outlook is characterized by pessimism, demoralization, or minor symptoms of anxiety and depression. One seminal aspect of self-esteem has garnered much research attention: self-efficacy (Bandura, 1977). Self-efficacy is defined as confidence in one’s own abilities to cope with adversity, either independently or by obtaining appropriate assistance from others. Self-efficacy is a major component of the construct known as resilience (i.e., the ability to withstand and overcome adversity). Other components of resilience include intelligence and problem solving, although resilience is also facilitated by having adequate social support (Beardslee & Vaillant, 1997).

Neuroticism
Neuroticism is a construct that refers to a broad pattern of psychological, emotional, and psychophysiologic reactivity (Eysenck & Eysenck, 1975). The opposite of neuroticism is stability or equanimity, which are major components of mental health. A high level of neuroticism is associated with a predisposition toward recognizing the dangerous, harmful, or defeating aspects of a situation and the tendency to respond with worry, anticipatory anxiety, emotionality, pessimism, and dissatisfaction. Neuroticism is associated with a greater risk of early-onset depressive and anxiety disorders (Clark et al., 1994). Neuroticism also may be linked to a particular cognitive attributional style in which life events are perceived to be large in impact and more difficult to change (Alloy et al., 1984). For example, this attributional style is embodied by pessimists who see every setback or failure as lasting forever, undermining everything, and being their fault (Seligman, 1991). Neuroticism also is associated with more rigid or distorted attitudes and beliefs about one’s competence (Beck, 1976).

Avoidance
Avoidance describes an exaggerated predisposition to withdraw from novel situations and to avoid personal challenges as threats. This is the behavioral state that often accompanies the distress of someone who has a high level of neuroticism and low self-efficacy (Vaughan & Oldham, 1997). Closely related to the characteristics of behavioral inhibition or introversion, the trait of avoidance appears to be partly inherited and is associated with shyness, anxiety, and depressive disorders in both childhood and adult life, as well as the subsequent development of substance abuse disorders (Vaughan & Oldham, 1997; Kagan et al., 1988). The people with low levels of harm avoidance are described as “healthy extroverts” and are characterized by confident, carefree, or outgoing behaviors.

Impulsivity
Impulsivity is a trait that is associated with poor modulation of emotions, especially anger, difficulty delaying gratification, and novelty seeking. There is some developmental continuity between high levels of impulsivity in childhood and several adult mental disorders, including attention deficit hyperactivity disorder, bipolar disorder, and substance abuse disorders (Svrakic et al., 1993; Rothbart & Ahadi, 1994). Impulsivity also is associated with physical abuse (both as victim and, subsequently, as perpetrator) and antisocial personality traits (Vaughan & Oldham, 1997).

Sociopathy
This set of traits and behaviors refers to the predisposition to engage in dishonest, hurtful, unfaithful, and at times dangerous conduct to benefit one’s own ends. The opposite of sociopathy may be referred to as character or scrupulosity. In its full form, sociopathy is referred to as antisocial personality disorder (DSM-IV). Sociopathy is characterized by a tendency and ability to disregard laws and rules, difficulties reciprocating within empathic and intimate relationships, less internalization of moral standards (i.e., a weaker conscience or superego), and an insensitivity to the needs and rights of others. People scoring high in sociopathy often have problems with aggressivity and are overrepresented among criminal populations. Although not invariably associated with criminality, sociopathy is associated with problematic, unethical, and morally questionable conduct in the workplace and within social systems. Marked sociopathy is much more common among men than women, although several other disorders (borderline and histrionic personality disorders and somatization disorder) are overrepresented among women within the same families (Widiger & Costa, 1994).

In summary, the various traits and behavioral patterns that epitomize strong mental health do not, of course, exist in a vacuum: they develop in a social context, and they underpin people’s ability to handle psychological and social adversity and the exposure to stressful life events. Furthermore, as reviewed in Chapter 3, severe or repeated trauma during youth may have enduring effects on both neurobiological and psychological development, altering stress responsivity and adult behavior patterns. Perhaps the best documented evidence of such enduring effects has been shown in young adults who experienced severe sexual or physical abuse in childhood. These individuals experience a greatly increased risk of mood, anxiety, and personality disorders throughout adult life.


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