of mind and body” that was criticized in the 1999 Surgeon General’s Report on Mental Health (DHHS, 1999:Preface and p. x). Since that report was released, evidence for the effects of mental and substance-use problems and illnesses on each other and on general health and health care continues to accumulate (Bush et al., 2005; Katon, 2003; Kroenke, 2003). Depression and anxiety disorders are strongly associated with somatic symptoms, such as headache, fatigue, dizziness, and pain, that are the leading cause of outpatient medical visits and often medically unexplained (Kroenke, 2003). Similarly, substance-use problems and illnesses contribute to the misdiagnosis, difficult management, and poor outcomes associated with many of the most pervasive medical illnesses in this country, such as chronic pain, sleep disorders, breast cancer, hypertension, diabetes, pneumonia, and asthma (Howard et al., 2004; Rehm et al., 2003; Saitz et al., 1997). A substantial portion of individuals with chronic physical illnesses also have a comorbid M/SU problem or illness. A nationally representative survey of Americans found that among respondents with the four most common chronic general illnesses (hypertension, arthritis, asthma, and ulcers), the loss of whole or partial work days was confined largely to those to those who had a co-occurring mental condition (Kessler et al., 2003).

Examining in detail the effect of just one type of mental illness (depression) on one general health care condition (heart attack), a recent Agency for Healthcare Research and Quality (AHRQ) Evidence Report/Technology Assessment found that approximately one in five patients hospitalized for a heart attack suffers from major depression, and that the evidence is “strikingly consistent” that post–heart attack depression significantly increases one’s risk of death from heart-related or other causes. Patients with depression are about three times more likely to die from a future heart attack or other heart problem. Fully 60–70 percent of individuals who become depressed when hospitalized for a heart attack continue to suffer from depression for 1–4 or more months after discharge, and during the first year following a heart attack, those with major depression can experience a delay in returning to work, worse quality of life, and worse physical and psychological health (Bush et al., 2005:5).

Overall Finding. Mental, substance-use, and general illnesses are highly interrelated, especially with respect to chronic illness and injury. Improving care delivery and health outcomes for any one of the three depends upon improving care delivery and outcomes for the others.


Overarching Recommendation 1. Health care for general, mental, and substance-use problems and illnesses must be delivered with an under-



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