Healthy People 2010—Conference Edition

Chapter 18 Mental Health and 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 under-recognized. Today, 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 sexes, and all educational and socioeconomic groups. Approximately 40 million Americans 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 (3 percent) in the past year.^{2, 3, 4} At least one in five children and adolescents between ages 9 and 17 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 Americans 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 65,¹⁰ with the
number of cases in the population doubling every 5 years of age after age 60. 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 Americans in one 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
Anxiety disorders encompass several discrete conditions, including panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobia. More common than other mental disorders, anxiety disorders affect as many as 19 million Americans 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 and over 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 Americans 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 over 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.¹⁹

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.⁸⁵ 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.

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