National Academies Press: OpenBook
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Caring for People with
Mental Health and
Substance Use Disorders
in Primary Care Settings

PROCEEDINGS OF A WORKSHOP

Laurene Graig, Kaitlyn Friedman, and Joe Alper, Rapporteurs

Forum on Mental Health and Substance Use Disorders

Board on Health Care Services

Board on Health Sciences Policy

Health and Medicine Division

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by Purchase Order No. 75FCMC19P0036 with the Centers for Medicare & Medicaid Services, Contract No. HHSN263201800029I, Order No. HHSN26300025 with the National Institutes of Health, and by Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research & Development, LLC, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter & Elizabeth Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-68268-8
International Standard Book Number-10: 0-309-68268-1
Digital Object Identifier: https://doi.org/10.17226/25927

Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2020 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Caring for people with mental health and substance use disorders in primary care settings: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25927.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Image

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Image

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

PLANNING COMMITTEE ON CARING FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN PRIMARY CARE SETTINGS1

DEIDRA ROACH (Co-Chair), Medical Project Officer, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health

RUTH SHIM (Co-Chair), Luke and Grace Kim Professor in Cultural Psychiatry, Associate Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis

JEFFREY A. BUCK, Senior Advisor for Behavioral Health, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services

W. PERRY DICKINSON, Director, Practice Innovation Program; Professor, Department of Family Medicine, University of Colorado (Representing the American Board of Family Medicine)

RICHARD G. FRANK, Professor of Health Economics, Department of Health Care Policy, Harvard Medical School

HOWARD H. GOLDMAN, Professor of Psychiatry, University of Maryland at Baltimore School of Medicine

PAMELA GREENBERG, President and Chief Executive Officer, Association for Behavioral Health and Wellness

CAREN HOWARD, Advocacy Manager, Mental Health America

R. KATHRYN McHUGH, Director, Stress, Anxiety, and Substance Use Laboratory; Associate Psychologist, Center of Excellence in Alcohol, Drugs, and Addiction, McLean Hospital; Assistant Professor of Psychology, Department of Psychiatry, Harvard Medical School (Representing the American Psychological Association)

KATHY PHAM, Director of Policy and Professional Affairs, American College of Clinical Pharmacy

MARTIN ROSENZWEIG, Chief Medical Officer, Optum Behavioral Health

ALEXANDER ROSS, Senior Behavioral Health Advisor, Office of Planning, Evaluation, and Analysis, Health Resources and Services Administration

MATTHEW TIERNEY, Associate Clinical Faculty, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association)

___________________

1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Project Staff

LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer

KAITLYN FRIEDMAN, Research Associate

ANESIA WILKS, Senior Program Assistant

SHARYL NASS, Senior Director, Board on Health Care Services

ANDREW M. POPE, Senior Director, Board on Health Sciences Policy

Consultant

JOE ALPER, Writer

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

FORUM ON MENTAL HEALTH AND SUBSTANCE USE DISORDERS1

COLLEEN L. BARRY (Co-Chair), Johns Hopkins Bloomberg School of Public Health

HOWARD H. GOLDMAN (Co-Chair), University of Maryland at Baltimore School of Medicine

MARGARITA ALEGRÍA, Harvard Medical School

DARA BLACHMAN-DEMNER, Office of Behavioral and Social Sciences Research, National Institutes of Health

CARLOS BLANCO, National Institute on Drug Abuse, National Institutes of Health

DARLA SPENCE COFFEY, Council on Social Work Education

W. PERRY DICKINSON, University of Colorado (Representing the American Board of Family Medicine)

ROBERT FORMAN, Alkermes, Inc.

RICHARD G. FRANK, Harvard Medical School

CHELSEY GODDARD, Education Development Center

ALTHEA N. GRANT-LENZY, Centers for Disease Control and Prevention

PAMELA GREENBERG, Association for Behavioral Health and Wellness

LARKE NAHME HUANG, Substance Abuse and Mental Health Services Administration

KRISTIN KROEGER, American Psychiatric Association

LAUREN B. LOWENSTEIN, Centers for Medicare & Medicaid Services

HUSSEINI K. MANJI, Janssen Research & Development, LLC

R. KATHRYN McHUGH, McLean Hospital and Harvard Medical School (Representing the American Psychological Association)

BENJAMIN MILLER, Well Being Trust

ANNIE PETERS, National Association of Addiction Treatment Providers

KATHY PHAM, American College of Clinical Pharmacy

JOE PYLE, Scattergood Foundation (Representing Think Bigger Do Good Policy Series)

DEIDRA ROACH, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health

MARTIN ROSENZWEIG, Optum Behavioral Health

ALEXANDER ROSS, Health Resources and Services Administration

RUTH SHIM, University of California, Davis

___________________

1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

MATTHEW TIERNEY, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association)

MICHAEL TOEDT, Indian Health Service

Forum on Mental Health and Substance Use Disorders Staff

LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer

KAITLYN FRIEDMAN, Research Associate

ANESIA WILKS, Senior Program Assistant

MICAH WINOGRAD, Senior Finance Business Partner

SHARYL NASS, Senior Director, Board on Health Care Services

ANDREW M. POPE, Senior Director, Board on Health Sciences Policy

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.

We thank the following individuals for their review of this proceedings:

KIRSTEN BERONIO, National Association for Behavioral Healthcare

LYDIA CHWASTIAK, University of Washington

BETH McGINTY, Johns Hopkins Bloomberg School of Public Health

GREGORY E. SIMON, Kaiser Permanente

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings, nor did they see the final draft before its release. The review of this proceedings was overseen by KENNETH B. WELLS, University of California, Los Angeles. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Acknowledgments

The National Academies of Sciences, Engineering, and Medicine’s Forum on Mental Health and Substance Use Disorders wishes to express its sincere gratitude to the planning committee co-chairs Deidra Roach and Ruth Shim for their valuable contributions to the development and organization of this workshop. The forum wishes to thank all the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, the forum wants to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants.

Support from the many sponsors of the Forum on Mental Health and Substance Use Disorders is critical to the forum’s work. The sponsors include the Centers for Medicare & Medicaid Services and National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and Office of Behavioral and Social Sciences Research of the National Institutes of Health and Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research & Development, LLC, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter & Elizabeth Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×

Acronyms and Abbreviations

ACO accountable care organization
AIMS Advancing Integrated Mental Health Solutions
CETA Common Elements Treatment Approach
CMMI Center for Medicare & Medicaid Innovation
CMS Centers for Medicare & Medicaid Services
COVID-19 coronavirus disease 2019
CPC+ Comprehensive Primary Care Plus
DBSA Depression and Bipolar Support Alliance
ED emergency department
EHR electronic health record
FQHC federally qualified health center
HRSA Health Resources and Services Administration
IBH-PC integrated behavioral health in primary care
IMPACT Improving Mood-Promoting Access to Collaborative Treatment
IOM Institute of Medicine
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
MAT medication-assisted treatment
MHSUD mental health and substance use disorder
NIAAA National Institute on Alcohol Abuse and Alcoholism
OBAT Office-Based Addiction Treatment
OTP opioid treatment program
OUD opioid use disorder
PCMH patient-centered medical home
Pharm.D. doctor of pharmacy
PHQ-9 Patient Health Questionnaire major depressive disorder module
SBI Screening and Brief Intervention
SBIRT Screening, Brief Intervention, and Referral to Treatment
SUD substance use disorder
VA U.S. Department of Veterans Affairs
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R1
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R2
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R3
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R4
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R5
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R6
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R7
Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R8
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R9
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R10
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R11
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R12
Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R13
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R14
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R15
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R16
Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R17
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
×
Page R18
Next: Proceedings of a Workshop »
Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop Get This Book
×
Buy Paperback | $55.00 Buy Ebook | $44.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Behavioral health conditions, which include mental health and substance use disorders, affect approximately 20 percent of Americans. Of those with a substance use disorder, approximately 60 percent also have a mental health disorder. As many as 80 percent of patients with behavioral health conditions seek treatment in emergency rooms and primary care clinics, and between 60 and 70 percent of them are discharged without receiving behavioral health care services. More than two-thirds of primary care providers report that they are unable to connect patients with behavioral health providers because of a shortage of mental health providers and health insurance barriers. Part of the explanation for the lack of access to care lies in a historical legacy of discrimination and stigma that makes people reluctant to seek help and also led to segregated and inhumane services for those facing mental health and substance use disorders.

In an effort to understanding the challenges and opportunities of providing essential components of care for people with mental health and substance use disorders in primary care settings, the National Academies of Sciences, Engineering, and Medicine's Forum on Mental Health and Substance Use Disorders convened three webinars held on June 3, July 29, and August 26, 2020. The webinars addressed efforts to define essential components of care for people with mental health and substance use disorders in the primary care setting for depression, alcohol use disorders, and opioid use disorders; opportunities to build the health care workforce and delivery models that incorporate those essential components of care; and financial incentives and payment structures to support the implementation of those care models, including value-based payment strategies and practice-level incentives. This publication summarizes the presentations and discussion of the webinars.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!