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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