Section 1: Looking Ahead and Reflecting Upon the Past

Chapter 1. Where Is Mental Health Likely to Be a Century Hence?
An Editorial Perspective

Ronald W. Manderscheid, Ph. D., and Marilyn J. Henderson, M.P.A.

Center for Mental Health Services Substance Abuse and Mental Health Services Administration

Introduction

As we prepare this edition of Mental Health, United States, we think it important to provide some hints about the future of mental health from the vantage point of a new century. We do this with trepidation. A century hence, what we portray here will be judged from the perspective of hindsight. Nevertheless, we believe that the 21st century will offer exciting and sometimes astonishing developments for all areas of health, including mental health.

In mental health, we expect developments to occur across a broad spectrum over the next century. Below, we have tried to capture these trends in four predictions or scenarios. These predictions relate to the roles we will assign to persons with mental illness in our society in the future and to how mental illness will be treated. Clearly, these two areas interact with each other. Their interaction will be a major determinant in how each prediction fares.

Major Predictions

Human rights will be established as fundamental in our health care system. It seems strangely odd that the major human rights abuses of the 20th century have not yet stimulated protections that are codified in our culture and our laws. Major efforts are currently under way to guarantee patients' rights in the health care system and consumer and family rights in mental health. These efforts are reflective of an underlying civil rights concern that portends further change. Human rights, patient rights, consumer rights, and family rights are mutually reinforcing. A new organization, Public Health Advocates, is emerging. This entity will serve as a rallying point in all local communities for advocacy about all health care issues. Clearly, people want change in the health care system and they are willing to organize to achieve it.

We expect these current efforts to culminate in significant human rights protections with regard to health care. For mental health, this will include protections that ensure the right to human dignity, the right to choose care and to participate in decisions about care, the right to provide feedback about the quality of care, and the right to expect that care will result in significant improvement.

Such rights will mean little unless fundamental needs are also met. Included are such basic needs as communities that protect against violence, adequate housing and appropriate education for all, and productive roles that promote self-esteem and well-being. We expect significant progress to be made over the next century in each of these areas as well.

Consumers and family members will seek and be given more responsibility for health and health care. Major growth in self-and peer-support activities is indicative of a shift in the balance of consumer and provider roles in the health care system. We now speak of consumer-and family-centered services and consumer-and family-centered outcomes in mental health care. These momentous changes would have been unthinkable only a few short years ago.

Growth of consumer and family rights in mental health will be accompanied by an expansion of responsibility for one's own well-being. If efforts to promote mental well-being and to intervene early in mental health problems are to be successful, nothing less will suffice. Clearly, we are moving toward a prevention and early intervention focus.

We expect the focus on human rights and the focus on prevention and early intervention to lead to an expansion of individual responsibility for one's own health in the 21st century. To be successful, these shifts must be accompanied by appropriate training and broad availability of information to aid decision and action. In mental health, expansion of consumer and family responsibility will take the form of decisionmaking about personal prevention and intervention activities, as well as decisionmaking about what types of care will be deemed appropriate and what the course of care will be. Self-and peer-support activities will expand dramatically to provide the necessary information and support to facilitate these decisions.

Technology will become a primary vehicle for delivering health care. At the present time, telecommunication, computer, and Internet technology are being linked to offer "care at a distance." In other words, the technology has been used to link consumers and providers much as one would have used a telephone in the past. Thus, several thousand websites offer psychotherapy. Such efforts represent only a primitive beginning to a technology revolution that will sweep through the health care system.

Rapid advances are being made in voice-activated automated response systems and in the application of artificial intelligence systems to real-world problems. Efforts are currently under way, for example, to develop websites that incorporate artificial intelligence systems without real-time participation by providers. These systems are being designed to learn about consumers through interaction with them and then to provide customized therapy based upon the responses consumers offer. A simple example is a current website that provides advice about depression.

At the same time, other systems are being developed to permit people to remain in their homes and yet to monitor their health status from day to day. Such systems will increase the independence of many frail elderly and disabled persons. It will also expand dramatically our capacity to provide care to these populations.

We expect that the new technology will advance to the point that many tasks now carried out by providers will ultimately be carried out by artificial intelligence systems. The Internet, video cable systems, and wireless communication will all serve as channels to provide this care. Mental health seems to be particularly suited to this new technology, since much of the care provided is based upon human interaction. Care must be exercised to ensure quality of service delivery through such systems.

Genetic treatments for biologically based disorders will become routine. As of publication, the first complete mapping of the human genome has just been completed. This map will provide the foundation for us to identify, treat, and prevent genetically based disorders. Genetic interventions will advance rapidly once the map is available because biotechnology firms are already poised to identify and test new interventions.

We expect that genetic interventions for biologically based mental disorders will be commonplace by the end of the 21st century. Results will be both revolutionary and breathtaking. Imagine for a moment the elimination of genetically based diseases. This is clearly within our grasp.

Final Word

The four major predictions identified here need to occur simultaneously if the best outcomes are to be achieved by the end of the 21st century. For example, extensive genetic engineering without human rights protections would constitute a disaster from our point of view. We also assert that our future needs to be created. We should not just wait for events to unfold. Each of us has a major role to play in constructing the future we desire.

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