18 Mental Health and Mental Disorders

Goal

Improve mental health and ensure access to appropriate, quality mental health services.

Overview

Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and contribution to community or society. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof), which are associated with distress and/or impaired functioning and spawn a host of human problems that may include disability, pain, or death. Mental illness is the term that refers collectively to all diagnosable mental disorders.

Issues

Mental disorders generate an immense public health burden of disability. The World Health Organization, in collaboration with the World Bank and Harvard University, has determined the “burden of disability” associated with the whole range of diseases and health conditions suffered by peoples throughout the world. A striking finding of the landmark Global Burden of Disease study is that the impact of mental illness on overall health and productivity in the United States and throughout the world often is profoundly underrecognized. In established market economies such as the United States, mental illness is on a par with heart disease and cancer as a cause of disability.[1] Suicide—a major public health problem in the United States—occurs most frequently as a consequence of a mental disorder.

Mental disorders occur across the lifespan, affecting persons of all racial and ethnic groups, both genders, and all educational and socioeconomic groups. In the United States approximately 40 million people aged 18 to 64 years, or 22 percent of the population, had a diagnosis of mental disorder alone (19 percent) or of a co-occurring mental and addictive disorder in the past year.[2], [3], [4] At least one in five children and adolescents between age 9 and 17 years has a diagnosable mental disorder in a given year.[5] Mental and behavioral disorders and serious emotional disturbances (SEDs) in children and adolescents can lead to school failure, alcohol or illicit drug use, violence, or suicide.[6], [7], [8] About 5 percent of children and adolescents are extremely impaired by mental, behavioral, and emotional disorders.[9] In later life, the majority of people aged 65 years and older cope constructively with the changes associated with aging and maintain mental health, yet an estimated 25 percent of older people (8.6 million) experience specific mental disorders, such as depression, anxiety, substance abuse, and dementia, that are not part of normal aging. Alzheimer’s disease strikes 8 to 15 percent of people over age 65 years,[10] with the number of cases in the population doubling every 5 years of age after age 60 years. Alzheimer’s disease is thought to be responsible for 60 to 70 percent of all cases of dementia and is one of the leading causes of nursing home placements.[11]

Mental disorders vary in severity and in their impact on people’s lives. Mental disorders—such as schizophrenia, major depression and manic depressive or bipolar illness, and obsessive-compulsive disorder and panic disorder—can be enormously disabling.

Schizophrenia will affect more than 2 million people in the United States in 1 year.3 The disorder tends to follow a long-term course, although the severity of symptoms may wax and wane. With modern treatments, increasing numbers of persons with schizophrenia can and do view recovery as an achievable goal.

Affective disorders, which encompass major depression and manic depressive illness, constitute a second category of severe mental illness. The World Health Organization found major depression to be the leading cause of disability among adults in developed nations such as the United States.1 About 6.5 percent of women and 3.3 percent of men will have major depression in any year. Manic depressive illness affects around 1 percent of adults, with comparable rates of occurrence in men and women. A high rate of suicide is associated with such mood disorders.[12]

n	Anxiety disorders encompass several discrete conditions, including panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and phobia. More common than other mental disorders, anxiety disorders affect as many as 19 million people in the United States annually.[13]

Modern treatments for mental disorders are highly effective, with a variety of treatment options available for most disorders; there is no “one size fits all” treatment. Similarly, there exists today a diverse array of treatment settings, and a person may have the option of selecting a setting based on health care coverage, the clinical needs associated with a particular type or stage of illness, and personal preference.

Prevention scientists have developed, tested, and structured preventive interventions against depression, conduct disorder, and other adverse outcomes in high-risk groups of children. When applied with fidelity, preventive interventions can decrease risk of onset or delay onset of a disorder.

Rates for the most severe forms of mental disorders have been estimated to be between 2.6 and 2.8 percent of adults aged 18 years and older during any one year.13, [14] Despite the effectiveness of treatment and the many paths to obtaining a treatment of choice, only 25 percent of persons with a mental disorder obtain help for their illness in the health care system. In comparison, 60 to 80 percent of persons with heart disease seek and receive care.[15] More critically, 40 percent of all people who have a severe mental illness do not seek treatment from either general medical or specialty mental health providers. Indeed, the majority of persons with mental disorders do not receive mental health services. Of those aged 18 years and older getting help, about 15 percent receive help from mental health specialists.3 Of young people aged 9 to 17 years who have a mental disorder, 27 percent receive treatment in the health sector.[16] However, an additional 20 percent of children and adolescents with mental disorders use mental health services only in their schools.[17]

The direct costs of diagnosing and treating mental disorders totaled approximately $69 billion17 in 1996. Lost productivity and disability insurance payments due to illness or premature death accounted for an additional $74.9 billion.17 Crime, criminal justice costs, and property loss contributed another $6 billion to the total cost of mental illness. People with mental illnesses are overrepresented in jail populations; many do not receive treatment.[18] Of the $69 billion spent for diagnosing and treating mental disorders, nearly 70 percent was for the services of mental health specialty providers, with most of the remainder for general medical services providers. The majority—53 percent—of mental health treatment was paid for by public sector sources, including the States and local governments as well as Medicaid and Medicare and other Federal programs; 47 percent of expenditures were from private sources. Of expenditures from private sources, almost 60 percent were from private insurance.17 The remainder came from out-of-pocket payments, including insurance copayments, with a small amount from sources such as foundations.

Trends

Research on the brain and behavior in mental illness and mental health is moving at a rapid pace. An increasingly strong consumers’ movement in the mental health field is adding urgency to the tasks of translating new knowledge into clinical practices and refining service delivery systems to use new and emerging information optimally for patient/consumer needs. Consumer and family organizations, which formed out of concern over frequent fragmentation of mental health services and lack of accessibility to such services, have assumed a substantial role in supporting development of mental health services. Diverse groups share overlapping goals, including overcoming stigma and preventing discrimination toward persons with mental illness, promoting self-help groups, and promoting recovery from mental illness.18

The co-occurrence of addictive disorders among persons with mental disorders is gaining increasing attention from mental health professionals. Among adults aged 18 years and older with a lifetime history of any mental disorder, 29 percent have a history of an addictive disorder; of those with an alcohol disorder, 37 percent have had a mental disorder; and among those with other drug disorders, 53 percent have had a mental disorder.17 Having both mental and addictive disorders within the same year is a particularly significant clinical treatment issue, complicating treatment for each disorder. About 3 percent of the population aged 18 years and older has been identified as having co-occurring mental and addictive disorders in 1 year.3, 14 Of those with a serious mental illness, 15 percent have both types of disorder in 1 year, and of those with a severe and persistent mental illness, 27 percent have both mental and addictive disorders.14 Co-occurring, or comorbid, mental and addictive disorders are estimated to affect 50 to 60 percent of homeless persons.[19] Comorbid mental and addictive disorders also are evident in children and adolescents.[20] Especially at risk for alcohol use problems are boys diagnosed with so-called externalizing disorders such as conduct problems, oppositional-defiant disorder, and attention deficit/hyperactivity disorder (ADHD).[21] From public health promotion and disease prevention perspectives, it is noteworthy that children and adolescents with mental illnesses often do not become substance abusers until after the mental illness becomes apparent.[22] This time lag creates a window of opportunity when prevention of substance abuse in these children may be possible.20

As the life expectancy of individuals continues to grow longer, the sheer number—although not necessarily the proportion—of persons experiencing mental disorders of late life will expand. This trend will present society with unprecedented challenges in organizing, financing, and delivering effective preventive and treatment services for mental health in this population. As recognition continues to grow that depression and certain cognitive losses are treatable disorders and not inevitable concomitants of aging, diagnostic precision in later life and provision of targeted treatment are increasingly urgent.

Health care in the United States continues to undergo fundamental structural changes that require creative and flexible responses from service providers, administrators, researchers, and policymakers alike. Two prominent forces of change are Federal and State efforts to improve access to health care, including mental health care, and the rapid growth and impact of managed care. In 1998, the Mental Health Parity Act (P.L. 104-204) was implemented to help increase access to care. (The term “parity” or “mental health parity” refers generally to insurance coverage for mental health services that includes the same benefits and restrictions as coverage for other health services.) Although the Federal Mental Health Parity Act is quite limited in reducing insurance coverage discrepancies between physical and mental disorders, 53 percent of the U.S. population is now covered by State mental health parity laws.

Disparities

Although mental illnesses, for the most part, are equal opportunity disorders, there are some marked differences in how they present themselves and how they are prevented, diagnosed, and treated by gender, racial and ethnic group, and age.17

Differences between men and women are evident in the number of cases of particular mental disorders. For example, major depression affects approximately twice as many women as men.[23] Women who are poor, have little formal schooling, and are on welfare or are unemployed are more likely to experience depression than women in the general population. Anxiety, panic, and phobic disorders affect two to three times as many women as men.[24], [25], [26]

Risk for engaging in suicidal behaviors also differs by gender. A history of physical or sexual abuse appears to be a serious risk factor for suicide attempts in both women and men.[27], [28] Women attempt suicide more often than men,[29] but men’s risk of completed suicide is on average four and one half times higher than women’s.[30] This suicide gender gap begins in adolescence and grows through middle and later life.[31]

Specific mental disorders affect men and women at particular stages of life. Schizophrenia occurs more often in young men than in women and usually has its onset in the late teen and early adult years. Eating disorders, affecting up to 2 percent of the population, arise predominantly—but not exclusively—in adolescent and young adult women (90 percent of all cases); the median age of onset is 17 years.2 Eating disorders often persist into adulthood and have among the highest death rates of any mental disorder.[32] Alzheimer’s disease affects equal numbers of women and men, although women’s longer average life spans mean that more women than men have Alzheimer’s disease at any point in time.[33]

Mental disorders, in aggregate, are as common later in life as they are at other ages, although rates for specific mental disorders vary depending on age and gender.[34] In any one-year period, the number of cases of major depression in people aged 65 years and older is approximately 1 percent, which is about half the rate among persons aged 45 to 64 years.[35] Depression rates are much higher, however, among older people who experience a physical health problem—12 percent for persons hospitalized for problems such as hip fractures or heart disease.[36] Depression rates for older persons in nursing homes range from 15 to 25 percent.[37] The number of cases of dementias, such as Alzheimer’s disease and other severe losses of mental abilities, are as high as 12 percent among persons aged 65 years and older.[38] By age 85 years, the rate grows to 25 percent.[39]

In contrast, rates of primary psychotic disorders drop with age;[40] thus, schizophrenia and persistent paranoid disorders affect fewer than 0.5 percent of older adults.[41] Although fewer old persons attempt suicide than do young persons,[42] the rate of completed suicide is highest among elderly men, who account for about 80 percent of suicides among persons aged 65 years and older.[43] Moreover, elderly white men have a suicide rate six times the national average.[44]

Caution is needed, however, when discussing differences among racial and ethnic groups in the rates of mental illness. Studies of the number of cases of mental health problems among racial and ethnic populations, while increasing in number, remain limited and often inconclusive. Discussion of the rates of existing cases must consider differences in how persons of different cultures and racial and ethnic groups perceive mental illness. Behavioral problems that Western medicine views as signs of mental illness may be assessed differently by individuals in various racial and ethnic groups. With this caution in mind, along with the recognition that sample sizes for racial and ethnic groups may be limited, examination of existing large-scale studies for mental health trends among racial and ethnic groups remains important.

Mental disorders are not only the cause of limitations of various life activities but also can be a secondary problem among people with other disabilities. Depression and anxiety, for example, are seen more frequently among people with disabilities than those without disabilities.[45]

Opportunities

Promising universal and targeted preventive interventions, implemented according to scientific recommendations, have great potential to reduce the risk for mental disorders and the burden of suffering in vulnerable populations. Also, social and behavioral research is beginning to explore the concept of resilience to identify strengths that may promote health and healing. It is generally assumed that resilience involves the interaction of biological, psychological, and environmental processes. With increased understanding of how to identify and promote resilience, it will be possible to design effective programs that draw on such internal capacity.

There is increasing awareness and concern in the public health sector regarding the impact of stress, its prevention and treatment, and the need for enhanced coping skills. Stress may be experienced by any person and provides a clear demonstration of mind-body interaction. Coping skills, acquired throughout the lifespan, are positive adaptations that affect the ability to manage stressful events. Additional research can help quantify the public health burden of stress and identify ways to prevent or alleviate it through environmental or individual strategies.

Progress in fundamental science and an emphasis on translating new knowledge into clinical applications can strengthen opportunities for future clinical and service system innovations. Research-based treatments afford an unprecedented opportunity to achieve a major reduction in the burden of disease associated with mental illness. With enhancements of clinical services and service systems, recovery is an achievable objective of mental health clinical interventions.

Evidence that mental disorders are legitimate and highly responsive to appropriate treatment promises to be a potent antidote to stigma. Stigma creates barriers to providing and receiving competent and effective mental health treatment and can lead to inappropriate treatment, unemployment, and homelessness. The elimination of stigma associated with mental disorders will in turn encourage more individuals to seek needed mental health care.

Interim Progress Toward Year 2000 Objectives

Four Healthy People 2000 objectives focus on individual behavior in coping with the symptoms of mental disorders: controlling stress, seeking help with personal and emotional problems, obtaining treatment for depression, and using community support programs for severe and persistent disorders. The least progress was achieved on objectives indicative of chronic stress exposure; that is, controlling stress and seeking treatment for depression showed the least progress. Objectives that involve seeking help for personal and emotional problems that result from disabilities, particularly those associated with severe and persistent mental disorders, showed the most progress. Five Healthy People 2000 objectives focus on the development of service delivery mechanisms for early recognition of symptoms and interventions, as well as reductions in the negative consequences of mental disorders. A slight decline in the proportion of nurse practitioners who typically inquire about the parent-child relationship has been documented (from 55 percent to 51 percent). In addition, large declines have taken place in nurse practitioners who typically inquire about their adult patients’ cognitive, emotional, or behavioral functioning (from 35 percent to 19 percent for cognitive functioning and from 40 percent to 26 percent for emotional or behavioral functioning). Some offsetting increases in treatment and referral activity are reported (from 20 percent to 22 percent for cognitive problems, from 23 percent to 33 percent for emotional/behavioral problems).

Six Healthy People 2000 objectives focus on the distress and dysfunction that accompany the cognitive, emotional, and behavioral symptoms of mental disorders. The age-adjusted suicide rate in the total population has slightly declined and by 1997 already had met the target level; the rate for white men aged 65 years and older, who began the decade at highest risk for suicide (44.4 per 100,000), had declined below the year 2000 target in 1994 (38.9 per 100,000) and had declined further by 1997 (35.5 per 100,000).

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review 1998–99.

Healthy People 2010-Summary of Objectives

Mental Health and Mental Disorders

Goal: Improve mental health and ensure access to appropriate, quality mental health services.

Number	Objective Short Title
Mental Health Status Improvement
18-1	Suicide
18-2	Adolescent suicide attempts
18-3	Serious mental illness (SMI) among homeless adults
18-4	Employment of persons with SMI
18-5	Eating disorder relapses
Treatment Expansion
18-6	Primary care screening and assessment
18-7	Treatment for children with mental health problems
18-8	Juvenile justice facility screening
18-9	Treatment for adults with mental disorders
18-10	Treatment for co-occurring disorders
18-11	Adult jail diversion programs
State Activities
18-12	State tracking of consumer satisfaction
18-13	State plans addressing cultural competence
18-14	State plans addressing elderly persons

Healthy People 2010 Objectives

Mental Health Status Improvement


18-1.		Reduce the suicide rate.

Target: 5.0 suicides per 100,000 population.

Baseline: 11.3 suicides per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Suicides
Total Population, 1998	Rate per 100,000
TOTAL	11.3
Race and ethnicity
American Indian or Alaska Native	12.6
Asian or Pacific Islander	6.6
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	5.8
White	12.2

Hispanic or Latino	6.3
Not Hispanic or Latino	11.8
Black or African American	6.0
White	12.8
Gender
Female	4.3
Male	19.2
Education level (aged 25 to 64 years)
Less than high school	17.9
High school graduate	19.2
At least some college	10.0
Age (not age adjusted)
10 to 14 years	1.6
15 to 19 years	8.9
20 to 24 years	13.6

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.


18-2		Reduce the rate of suicide attempts by adolescents.

Target: 12-month average of 1 percent.

Baseline: 12-month average of 2.6 percent of adolescents in grades 9 through 12 attempted suicide in 1999.

Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Students in Grades 9 Through 12, 1999	Suicide Attempts
Students in Grades 9 Through 12, 1999	Percent
TOTAL	2.6
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DSU
Native Hawaiian and other Pacific Islander	DSU
Black or African American	3.1
White	2.2

Hispanic or Latino	3.0
Not Hispanic or Latino	2.6
Black or African American	2.9
White	1.9
Gender
Female	3.1
Male	2.1
Parents’ education level
Less than high school	DNC
High school graduate	DNC
At least some college	DNC
Sexual orientation	DNC

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Suicide is a complex behavior that can be prevented in many cases by early recognition and treatment of mental disorders. It was the ninth leading cause of death in the United States in 1996 and the third leading killer of young persons between age 15 and 24 years.[46], [47], [48], [49] At least 90 percent of all people who kill themselves have a mental or substance abuse disorder, or a combination of disorders. However, most persons with a mental or substance abuse disorder do not kill themselves; thus other factors contribute to suicide risk. In addition to mental and substance abuse disorders, risk factors include prior suicide attempt, stressful life events, and access to lethal suicide methods. Suicide is difficult to predict; therefore, preventive interventions focus on risk factors. Thus, reduction in access to lethal methods and recognition and treatment of mental and substance abuse disorders are among the most promising approaches to suicide prevention. More targeted approaches should consider risk factors most salient and appropriate for select populations.


18-3.		Reduce the proportion of homeless adults who have serious mental illness (SMI).

Target: 19 percent.

Baseline: 25 percent of homeless adults aged 18 years and older had SMI in 1996.

Target setting method: 24 percent improvement. (Better than the best will be used when data are available.)

Data source: Projects for Assistance in Transition from Homelessness (PATH) Annual Application, SAMHSA, CMHS.

Data for population groups currently are not collected.

Approximately one-quarter of homeless persons in the United States have a serious mental illness (SMI).[50] New approaches developed over the past 10 years provide ways to lower the number of persons who are homeless and who also have SMI. Using persistent patient outreach and engagement strategies, service providers are helping homeless persons with SMI connect with mainstream treatment systems.[51], [52]

Treatment alone, however, is not enough. Once permanent housing is located, appropriate mental health and social supports can help persons with mental illness remain off the street. Much of this support occurs in the form of case management, particularly if it is responsive both to emerging mental health issues and to the skills a person needs to function and thrive in the community.


18-4.		Increase the proportion of persons with serious mental illness (SMI) who are employed.

Target: 51 percent.

Baseline: 43 percent of persons aged 18 years and older with SMI were employed in 1994.

Target setting method: 19 percent improvement. (Better than the best will be used when data are available.)

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Data for population groups currently are not analyzed.

Rehabilitation is an essential part of care for adults with serious mental illness. To promote independent living, rehabilitation programs often evaluate and place these persons in jobs. Rehabilitation programs also provide continuing support and help ensure that the placement is working well. Research shows that working provides both economic and personal benefits for persons with SMI that extend beyond a paycheck and workplace companionship.[53] Employment also improves self-esteem and independence; it helps a person to manage his or her own illness and return to community life.[54], [55] A majority of persons with SMI want to be employed and rank employment as a primary personal goal.[56] Helping persons with mental illness secure employment can reduce the use of mental health services and reduce the number of persons who receive Federal and State disability payments.56


18-5.		(Developmental) Reduce the relapse rates for persons with eating disorders including anorexia nervosa and bulimia nervosa.

Potential data source: Prospective studies of patients with anorexia or bulimia nervosa, NIH, NIMH.

Anorexia nervosa is the most severe eating disorder, characterized by extreme and often life-threatening[57] weight loss associated with a distorted body image and a pathological fear of gaining weight. In cases of severe weight loss, hospital treatment often is needed. Studies suggest that from 30 to 50 percent of patients treated successfully in the hospital become ill again within 1 year of leaving the hospital.[58], [59] Efforts are under way to develop and test specific interventions that can prevent relapse in these patients. For instance, a particular kind of psychotherapy—called cognitive-behavioral treatment—has been found to lower relapse rates in persons with anorexia nervosa.[60] Treatments using medications also have been tried, both alone and in combination with talking therapy. Preliminary reports suggest that it might be possible to decrease the chance of relapse, resulting in better long-term prospects for persons with severe anorexia nervosa.

Bulimia nervosa is an eating disorder that involves eating a lot of food (binge eating) and then eliminating it (purging), whether through self-induced vomiting or through the use of diuretics or other medications. Effective short-term treatments exist for this serious mental health problem. When “remission” is defined as being symptom-free of binge eating and purging for at least 4 weeks, about 25 percent of those in remission had a relapse in less than 3 months. Around 9 months after remission, fewer than half (49 percent) of the persons remained symptom-free.[61] Risk for relapse seems to drop after 4 years of being symptom-free.[62]

Treatment Expansion


18-6.		(Developmental) Increase the number of persons seen in primary health care who receive mental health screening and assessment.

Potential data source: Primary Care Data System/Federally Qualified Health Centers, HRSA.

The general medical and primary care sector consists of health care professionals such as internists, pediatricians, and nurse practitioners in office-based practice, clinics, acute medical and surgical hospitals, and nursing homes. Close to 6 percent of the adult U.S. population use the general medical sector for mental health care, with an average of about 4 mental health visits per year—far lower than the average of 14 visits per year found in the specialty medical sector.3, 4 The general medical sector has long been identified as the initial point of contact for many adults with mental disorders; for some, these providers may be their only source of mental health services. This attention to mental state in primary care can promote early detection and intervention for mental health problems.


18-7.		(Developmental) Increase the proportion of children with mental health problems who receive treatment.

Potential data source: National Household Survey on Drug Abuse (NHSDA), SAMHSA, OAS.

For many children aged 18 years and under, lifelong mental disorders may start in childhood or adolescence. For many other children, normal development is disrupted by biological, environmental, and psychosocial factors, which impair their mental health, interfere with education and social interactions, and keep them from realizing their full potential as adults.

Expanding effective services for children, particularly for those with serious emotional disturbance, depends on promoting effective collaboration across critical areas of support: families, social services, health, mental health, juvenile justice, and schools. Better services and collaboration for children with serious emotional disturbance and their families will result in greater school retention, decreased contact with the juvenile justice system, increased stability of living arrangements, and improved educational, emotional, and behavioral development.[63], [64]


18-8.		(Developmental) Increase the proportion of juvenile justice facilities that screen new admissions for mental health problems.

Potential data source: Inventory of Mental Health Services in Juvenile Justice Facilities, SAMHSA.

It is estimated that over 100,000 youth are placed in juvenile justice facilities annually.[65] Although exact numbers of youths with mental disorders among those entering this system are not available, the proportion is considerably higher than in the general population. Not surprisingly, problems of suicide, self-injurious behavior, and other disorders are significant among youths in the juvenile justice system.[66] Screening activities, including parent or caregiver interviews, should be conducted by qualified mental health personnel.66 This approach can help ensure that all youths entering the juvenile justice system who also have a treatable mental health problem are identified and receive appropriate treatment.


18-9.		Increase the proportion of adults with mental disorders who receive treatment.

Target and baseline:

Objective	Increase in Adults With Mental Disorders Receiving Treatment	1997 Baseline (unless noted)	2010 Target
Objective		Percent
18-9a.	Adults aged 18 to 54 years with serious mental illness	47 (1991)	55
18-9b.	Adults aged 18 years and older with recognized depression	23	50
18-9c.	Adults aged 18 years and older with schizophrenia	60 (1984)	75
18-9d.	Adults aged 18 years and older with generalized anxiety disorder	38	50

Target setting method: 17 percent improvement for 18-9a. (Better than the best will be used when data are available.) Better than the best for 18-9b, 18-9c, and 18-9d.

Data sources: Epidemiologic Catchment Area (ECA) Program, NIH, NIMH; National Household Survey on Drug Abuse (NHSDA), SAMHSA, OAS; National Comorbidity Survey, SAMHSA, CMHS; NIH, NIMH.

Adults Aged 18 Years and Older With Mental Disorders, 1997 (unless noted)	Received Treatment
	18-9a. Serious Mental Illness (aged 18 to 54 years) (1991)	18-9b. Recog- nized Depres- sion	18-9c. Schizo- phrenia (1984)	18-9d. Gener- alized Anxiety Disorder
	Percent
TOTAL	47	23	60	38
Race and ethnicity
American Indian or Alaska Native	DNA	DSU	DSU	DSU
Asian or Pacific Islander	DNA	DSU	DSU	DSU
Asian	DNA	DNC	DSU	DNC
Native Hawaiian and other Pacific Islander	DNA	DNC	DSU	DNC
Black or African American	DNA	16	DNC	26
White	DNA	24	DNC	39

Hispanic or Latino	DNA	20	42	DSU
Not Hispanic or Latino	DNA	DNC	DNC	40
Black or African American	DNA	DNA	41	DNA
White	DNA	DNA	63	DNA
Gender
Female	DNA	24	63	32
Male	DNA	21	51	49
Education level
Less than high school	DNA	22	48	48
High school graduate	DNA	19	71	34
At least some college	DNA	28	66	32
Sexual orientation	DNC	DNC	DNC	DNC

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Serious mental illness. Untreated mental illnesses have human and economic costs associated with them[67], [68] Lost productivity due to illness, premature death, criminal justice interaction process, and property loss are all part of these costs. Ninety percent of those who complete suicide have a diagnosed mental illness.3 Helping persons with mental illnesses access appropriate scientifically based treatments is essential.

Depression. At some time or another, virtually all adults will experience a tragic or unexpected loss or a serious setback and times of profound sadness, grief, or distress. Major depressive disorder, however, differs both quantitatively and qualitatively from normal sadness or grief, which is typically less pervasive and generally more time-limited. Moreover, some of the symptoms of severe depression, such as anhedonia (the inability to experience pleasure), hopelessness, and loss of mood reactivity (the ability to feel a mood uplift in response to something positive) only rarely accompany normal sadness. Suicidal thou


Co-Lead Agencies:		National Institutes of Health Substance Abuse and Mental Health Services Administration