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14. Mental Health
Mental and emotional disabilities, according to the
National Mental Health Association (NMHA), ~con-
sume an astounding portion of our nation's re-
sources." The NMHA states that more than 19
percent of adults suffer from some mental or emo-
tional disorder. The direct costs of mental health
care were $24 billion in 1981, and the lost produc-
tivity costs were $29 billion." Despite these high
costs, many persons in need of care are not treated;
still others with underlying mental or emotional
problems are treated through the general health care
system, at a cost of many billions of dollars, without
ever being properly diagnosed. The NMHA reports
that many "patients seeking medical help do so
because of physical symptoms related primarily to
stress reactions or emotional problems." On the
positive side, however, the NMHA reports that "a
substantial and rapidly expanding knowledge base
exists to direct efforts in the prevention of mental-
emotional disabilities." ('tO70) The combination of
the high costs of mental illness and the potential
benefits to be attained through prevention led 75
testifiers to address their remarks primarily to this
subject and another 18 to make substantial comments.
According to Joan Reiss of the Sacramento-Placer
Mental Health Association in California:
Ask a group of people to tell you what they
think when they hear the words, "physical
health." Responses often include: exercise, mus-
cle tone, running, fitness, diet. Now ask the
same individuals to free associate with the words
"mental health." After a brief embarrassed si-
lence the thoughts flow: crazy, depressed, head-
ache, psycho, nuts, insane asylum. Physical
health conjures up positive images and mental
health brings on negative ones. Why? For
most of the population, mental health does not
mean health at all but refers to mental illness.
A major goal of the National Mental Health
Association by the year 2000 is to have the
general public believe that mental health refers
to a state of wellness as opposed to illness.
(~179)
Others, however, object to the NMHA's focus on
mental health and would prefer to see efforts con
centrated on Severe mental illnesses" such as schizo-
phrenia. Fewer people are afflicted with these
disorders, but they suffer much more. Although these
testifiers acknowledge that there are no proven
prevention strategies for severe mental illness, they
see great potential in biological, rather than psychoso-
cial, research. (#088; #278)
According to the NMHA, the risk factors for
mental and emotional disabilities Include genetic
heritage, physical vulnerability, family circumstances,
disruption of family stability and child nurturing, and
critical events such as bereavement, marital disruption,
or unemployment. Particularly at risk are those who
experience multiple stressors." The identification of
these risk factors is important because it can help
target information and possible preventive interven-
tions. (#070)
I he NMHA reports, however, that the current
application of this knowledge "in preventing mental-
emotional disabilities is creditable, but far from
sufficient." Many resources exist in state and local
government, businesses, health and mental health
agencies, and communities. These services, however,
"tend to be scattered, without comprehensive planning
and coordination, and are subject to funding cuts.
Diversity of programming is fruitful, but coordination
of efforts, with a clearer definition of prevention
Outcomes, improved taxonomy and standards of
effectiveness, is needed to move the field forward."
(#070)
The NMHA suggests four organizing principles to
serve as a framework for considering prevention
efforts:
1. Biological integrity: Because of the indivisibility
of physical and mental health, "good health care
addresses both medical and psychological concerns."
2. Psychosocial competence: "We can prevent some
mental-emotional disabilities by ensuring that
individuals have skills for relating to others and
capabilities to handle crises."
3. Social support: "We can prevent some mental-
emotional disabilities by helping people be involved
with others who provide nurturance, support. and
encouragement.
- rr -- A,
4. Societal policies and attitudes: The practices
and policies of organizations with which we are
involved through tout] lif~the hospital at birth, child
Mental Health 123
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care centers, schools, work, health care and social
service systems, and legal and government
agencies~an either enhance or hinder mental health
by affecting the development of competence or
because they are closely involved in critical life events
that result in greater risk for mental-emotional
disabilities." (#070)
lithe witnesses also identified a number of groups
in the population that are especially vulnerable to
mental health problems, particularly children, adoles-
cents, and older people. Prevention and early inter-
vention are of critical importance in the mental health
area, says Ernest Dahl of American River College.
Because of this, intensive prevention efforts on behalf
of children are needed; waiting to deal with the adult
is too late. (#047) For adolescents, suicide (~500)
and teenage pregnancy (~070) are seen as the critical
mental health problems (see also Chapters 4, 11, 16,
and 23~. For older adults, physical illnesses associated
with old age and the medication that people take for
these illnesses increase the risk of mental-emotional
disability. Older people also face such stressful life
events as forced retirement, death of a spouse, death
of relatives or friends, or moving or loss of home.
(~070)
PARTICULAR PROBLEMS
Much of the testimony on mental health issues
focused on three areas: stress, depression, and more
severe mental illnesses such as schizophrenia. Stress
and depression are more prevalent, and the witnesses
saw a greater potential for primary and' secondary
prevention. Schizophrenia and similar disorders are
less prevalent, but more devastating to the individuals
affected and their families. The current potential for
prevention of these disorders, however, is less promis-
ing, so many of the testifiers called for more research,
better treatment modalities, and better services.
Stress
"Despite its failure to conform to the medical model
of disease, stress illness is growing in impact and
importance," says George Benjamin of the National
Safety Council. "Because of fast changes in social,
job, and personal environments, more and more
people are reporting unbearable feelings of stress, of
just feeling sick," he says. (~019) The Laborers'
International Union of North America also calls for
more attention to the mental health impacts of job
124 Healthy People 2000: Citizens Chart the Course
loss and job change, to work-related and work-
associated mental health problems, and to the or-
ganization of work and its influence on stress.
(#586J
According to James Quick of the University of
Texas at Arlington, representing the American Psycho-
logical Association:
Stress is neither a disease process nor necessa-
rily bad. Used wisely, the stress response is a
very useful asset in responding to legitimate
emergencies and in achieving extraordinary peak
performances, such as in athletic competitions.
It is mismanaged stress that leads to a host of
health disorders.
Thus, Quick calls for stress education of the public
and of professionals, particularly for secondary school
students, college and university students, employees in
corporations, and members of professional associa-
tions. According to Quick, educational programs
should cover (1) knowledge of stress and its causes,
(2) knowledge of individual and collective costs of
mismanaged stress, (3) how to diagnose stress and its
effects, and (4) knowledge of "responsible individual
and organizational prevention strategies that are
beneficial in the management of stress.n (~176)
Depression
Roseann Scott and others from the University of
Colorado Health Sciences Center report that depres-
sion affects millions of people per year. They suggest
a number of strategies for dealing with depression,
including training school counselors and teachers to
recognize its symptoms, comprehensive psychiatric
evaluations of adolescents with drinking problems,
counseling new mothers at risk for postpartum
depression, and providing follow-up treatment for
hospital patients with identified depressive symptoms.
(#015)
Stephen Goldston of the University of California,
Los Angeles says that bereavement is a major cause
of depression. Community mental health centers
could help by providing (1) specific preventive ser-
vices for widows and widowers, parents who have lost
a child, children who have lost a parent or sibling,
and the family of a suicide victim; (2) death education
programs for parents and teachers; and (3) training
programs on death, dying, grief, and bereavement for
care givers. (#280)
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Schizophrenia and Other Serious Mental
Illnesses
Writing about schizophrenia, Dale Johnson of the
University of Houston reports:
Each year from 100,000 to 200,000 Americans,
mostly adolescents or young adults, develop this
dread disorder. For nearly all, the onset is
marked by psychiatric hospitalization, and for
the vast majority this is followed by a life of
recurrent psychotic episodes, impaired social
relations, joblessness, and abject poverty. The
mentally ill are profoundly lonely, isolated, and
vulnerable to stress. (#325)
Antipsychotic medications that were introduced in
the 1950s, reports Johnson, have provided some relief
from major symptoms and protection from stress, but
have not altered the basic course of the disease.
f#325) Floyd Bloom of the Scripps Clinic and
Research Foundation, however, estimates that prompt
treatment will reverse, significantly improve, or reduce
relapse in one-quarter to one-third of schizophrenia
cases.2 The NMHA reports:
We do not yet know how to prevent schizo-
phrenia or major depressive disorders. Encour-
aging advances are being made in epidemiologi-
cal, biomedical, neurological, and behavioral
science research. Eventual success in prevent-
ing these disorders will require support or
research in all these approaches and active
collaboration among researchers. f#O70J
Johnson, representing the National Alliance for the
Mentally Ill and the American Psychological Associa-
tion, sees the hospital relapse rate for schizophrenia
as too high and calls for action on this front. Lower-
ing the relapse rate will entail less restrictive treat-
ment and rehabilitation environments; continuity of
care; adequate housing and protection against econo-
mic need; better education and training for caretakers,
including family members; use of social learning
methods to decrease unacceptable behavior and
increase desirable behavior; and rehabilitation senaces,
including supported employment, education, and skills
training. (~325)
Many of the witnesses focused on the stigma
associated with mental illness. Donald Richardson,
representing the National Alliance for the Mentally
Ill, says that "stigma contributes to insurance dis
crimination, housing discrimination, employment
discrimination, and fosters client resistance to treat-
ment. The public must be made aware of the fact
that mental illness is a no-fault physical illness and
not a character defect." (#278)
INTERVENTIONS
The NMHA identifies four program areas that have
"immediate potential for reducing mental-emotional
disabilities: wanted and healthy babies; prevention of
adolescent pregnancy; school programs; and support,
information, and training for those in situations of
extreme stress." (~070)
Wanted and Healthy Babies
According to the NMHA:
Preventing mental-emotional disabilities can
begin before birth by ensuring healthy, wanted,
full-term babies. Society can increase the chan-
ces that a pregnancy is wanted by fostering the
development of responsible decision making,
providing reproductive and sex education at
home and in schools, and making family plan-
ning services accessible. The media can play an
important role by portraying responsible, rather
than glamorous or casual, sexual attitudes and
behavior. (~070)
According to Betty Tableman of the Michigan
Department of Mental Health, facilitating attachment
and parent-infant interaction would reduce low birth
weight, cultural mental retardation, and damage from
child abuse or neglect, as well as emotional and
conduct disorders. Prenatal care settings and hospital
maternity units should screen women for psychosocial
risk. (#418)
The Mental Health Association in Texas calls for
voluntary parenthood education programs to prevent
mental, emotional, and health problems in the child's
first years and unemployment or dependency in the
longer term. Services should be available from
pregnancy through preschool years, according to
association representative Betty Jo Hay, and should
provide "developmental screening and training and
support sentences to help parents to enhance their
children's intellectual, language, physical, and social
development." One such program, the Perry Pre-
school Project in Michigan, reported that 19 years
after the project, participating children had graduated
Mental Health 125
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from high school and gone on to jobs or further
education at twice the rate of children without the
program.3 (#091)
Prevention of Adolescent Pregnancy
Adolescent pregnancies result in more than half a
million births each year, 50 percent of them to
unmarried teens;4 these pregnancies constitute a
significant risk factor for mental-emotional disturban-
ces in both mother and child. (#070J Several wit-
nesses saw the prevention of adolescent and teen
pregnancies as a key factor in helping ensure the
mental health of current and future generations.
The effect of teen pregnancy and parenting touch
not only the mother and child, but also the father,
their families, and society as a whole, says Jackie
Rose of the Clackamas County Department of Human
Services in Oregon. Among the problems resulting
from births to young parents are low educational
achievement, unemployment, single parenting, divorce,
poverty, welfare dependency, pregnan~y-related health
risks, infant mortality, neglect, abuse, out-of-home
placements, and juvenile court placements. (~343J
Some groups of adolescents may require special
attention, according to Peggy Smith, representing the
American College of Obstetricians and Gynecologists,
whose data suggest that Biological and sociological
factors may interact to generate a group of Hispanic
teens especially vulnerable for early pregnancy." To
effectively address the needs of these young girls,
Smith calls for the use of bilingual staffs in state
agencies dealing with them, as well as research into
the effect of acculturation and its impact on health
care practices, including contraceptive use and
maternity needs. (#308)
Some programs already have proven success in
reaching juniors and seniors, according to the
American School Health Association. One program
of education, counseling, and medical and contracep-
tive services offered at a clinic located near the school
resulted in a 30 percent decline in the pregnancy rate
for those in the school program after 28 months, but
a 57.6 percent increase in pregnancies among those
not in the program during the same period.5 (~006)
To help prevent adolescent pregnancies, the
NMHA calls for Cooperative efforts by parents,
schools, and other social service agencies to prevent
adolescent pregnancy, through programs to develop
responsible decision making, provide health and sex
education programs that emphasize the consequences
of sexual act~vibr, and ensure access to counseling
126 Healthy People 2000: Citizens Chart the Course
about contraception and health sentences." (~070)
Such programs are discussed at length in Chapter 23.
School Programs
Programs in schools-preschool through high
school-that incorporate validated mental health strate-
gies and competence building as an integral part of
the curriculum" can help prevent mental-emotional
disorders, according to the NMHA (~070)
Kevin Dwyer of the National Association of School
Psychologists advocates prevention of mental health
problems of children through a cascade of interdisci-
plinary, interagency, communin,r-based preventive and
treatment interventions. Such programs would Help
children's social and interpersonal adjustment, increase
their resistance to mental health problems, and
improve their long-term ability to contribute meaning-
fully to society." Schools must help address the
personal, emotional, and social development and
concerns of students. Programs should include com-
munity awareness efforts; parent and care-giver
education; preschool programs to teach social skills,
problem solving, and communication; programs for
school-aged children and youth that stress problem
solving and building self-esteem; teen programs that
focus on problem solving, conflict resolution, positive
peer socialization, and the responsibilities of adult-
hood; and crisis intervention programs. (~802)
Other testifiers suggested more specific programs
for the schools, namely art and dance therapy. Ac-
cording to Ellen Speert of Los Angeles, "Art therapy
aids in the integration of a healthier sense of self. By
increasing creativity, it enhances both effective
problem solving and self-esteem." (~477J Marcia
Leventhal of New York University and Nancy
BrooksSchmitz of Columbia University report that
dance can increase self-esteem and self-awareness,
relieve tension, heal and strengthen the body, and
provide a means of social communication. (~595J
Support, Information, and Training In Situations
of Extreme Stress
According to the NMHA, Programs that help child-
ren and adults to anticipate and manage adverse life
circumstances or critical life events-programs such as
home visits to high-risk families with infants, training
in coping skills and mutual support groups" also offer
potential for reducing mental-emotional disabilities.
(~070J
Reiss says that 15 million people in the United
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states are currently involved in a half million self-
help or mutual support groups.6 (#179) Audrey
Gartner of the National Self-Help Clearinghouse adds,
"Over the past decade, self-help mutual support
groups have become an important way of helping
people cope with various life crises. Groups have
organized to help individual members deal with a
wide range of health-related and other problems."
(~427) For instance, the NMHA reports that
"mutual help groups, such as Widow to Widow
programs, have been found effective in dealing with
bereavement. Programs to increase the social involve-
ment of older people in the community have shown
positive effects on mental health and life satisfaction."
(~070J
IMPLEMENTATION
A number of implementation issues were raised by
testifiers, especially the integration of mental health
and other health services, the overall organization and
funding of prevention programs, and the need for
better surveillance data and more research.
Henry Leuchter, President of the Mental Health
Association of Franklin County in Ohio, and others
say that mental health services should not be treated
as separate from other health services. Adequate
planning for all health services requires integration,
consensus, and communication. (~130)
Goldston points out that "the number of state
departments of mental health with a designated unit
responsible for prevention, with adequate budget and
administrative structure, should be increased-there
are currently five. "The number of employers and
insurers supporting prevention efforts by including
coverage for prevention activities in benefit plans and
insurance packages should be increased," says
Goldston. (#280)
The American Association of Child and Adolescent
Psychiatry Is particularly concerned with services for
children. The number of children and adolescents at
risk for psychiatric illness is overwhelming and grow
REFERENCES
ing, they say, whereas federal resources for services
and training are shrinking. Prevention programs that
do exist are highly fragmented; a systems approach is
needed to combine outreach programs, needs assess-
ment, treatment training, and technical assistance
options. (#009)
~ .` ,.. .
-tne NMliA suggests an objective based on the
belief that no adequate surveillance system exists for
mental health issues.
By the year 2000, the federal government shall
establish a periodic process for determining the
extent and scope of mental health problems
relative to general health. The 1984 Epidemio-
logical Catchment Area (ECA) Study conducted
by NIMH provided valuable information on the
prevalence of mental disorders. Unfortunately
such data are unusual; there is not adequate,
accessible data on mental health needs, services,
and so on. The value of the ECA study is
heightened by the general difficulty in obtaining
mental health data. Factors such as consistency
in diagnostic terminology, confidentiality, and
involvement of multiple agencies can affect the
validity of mental health statistics. (#070)
Most witnesses agreed that more federal funds
should go to research on mental illness. For example,
Beverly Long of the World Federation for Mental
Health says that "it makes no sense to allocate 5
percent of the health research dollars to mental
health when one-fourth to one-half of the hospital
beds in the U.S. are occupied by those diagnosed as
'mentally ill'." (~270)
Beverly Banyay, representing the Mental Health
Association in Pennsylvania, points out that preven-
tion interventions take time to develop and must be
carefully evaluated. She calls for more well-designed,
multidisciplinary research and demonstration projects
on screening, diagnosis, and evaluation strategies for
all age groups. Longitudinal research is especially
necessary because the effects of prevention programs
occur over lifetimes, not months. (~014)
1. Commission on the Prevention of Mental-Emotional Disabilities: The Prevention of Mental-Emotional
Disabilities. Alexandria, Va.: National Mental Health Association, April 1986
2. Warner R: Recovery from Schizophrenia Boston: Routledge & Kegan Paul, 1985
Mental Health 127
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3. Barnett WS: Benefit cost analysis of the Perry Preschool Program and its implications. Education Evaluation
and Policy Analysis 7~4~:333-42, 1985
4. Wallace HM, Ryan G Jr., Oglesby AC (Eds.~: Maternal and Child Health Practices (3rd Edition). Oakland,
Cal: Third Party Publishing Company, 1988
5. Zabin LS, Hirsch MB, Smith EA, et al.: Evaluation of a pregnancy prevention program for urban teenagers.
Fam Plann Perspect 18(3):119-126, 1986
6. Gartner A, Gartner A, Kobasa SO: Self help. Handbook of Behavioral Medicine for Women. Edited by EA
Blechman, KD Brownell. New York: Pergamon Press, 1988
TESTIFIERS CITED IN CHAPTER 14
006 Allensworth, Diane; American School Health Association
009 Anthony, Virginia; American Association of Child and Adolescent Psychiatry
014 Banyay, Beverly; Community College of Beaver County (Pennsylvania)
015 Scott, Roseann; University of Colorado Health Sciences Center
019 Benjamin, George; National Safety Council
047 Dahl, Ernest; American River College (Sacramento)
070 Garrison, Preston; National Mental Health Association
088 Havel, Jim; The National Alliance for the Mentally Ill
091 Hay, Betty Jo; Mental Health Association in Texas
130 Leuchter, Henry; Mental Health Association of Franklin County (Ohio)
176 Quick, James; University of Texas at Arlington
179 Reiss, Joan; Mental Health Association, Sacramento-Placer
270 Long, Beverly; World Federation for Mental Health
278 Richardson, Donald; Los Angeles, California
280 Goldston, Stephen; University of California, Los Angeles
308 Smith, Peggy B.; Baylor College of Medicine
325 Johnson, Dale; University of Houston
343 Rose, Jackie; Clackamas County Department of Human Services (Oregon)
418 Tableman, Betty; Michigan Department of Mental Health
427 Gartner, Audrey; National Self-Help Clearinghouse
477 Speert, Ellen; American Art Therapy Association
500 Medrano, Martha; University of Texas Health Science Center at San Antonio
586 Fosco, Angelo; Laborers' International Union of North America
595 Leventhal, Marcia; New York University and BrooksSchmitz, Nancy; Columbia University
802 Dwyer, Kevin; National Association of School Psychologists
128 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
mental illness
