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I was inspired by this particular chapter of the Surgeon General's Report on Mental Health.
The following is Chapter 8 of the Surgeon General's Report on mental health. It is only one chapter of many. For the full text of the report go to http://www.mentalhealth.org/specials/surgeongeneralreport/home.html |
__________________________ Message from Donna E. Shalala ____________________CHAPTER 8 - Vision for the Future____________________ Mental health is fundamental to health and human functioning. Yet much more is known about mental illness than about mental health. Mental illnesses are real health conditions that are characterized by alterations in thinking, mood, or behaviorall mental, behavioral, and psychological symptoms mediated by the brain. Mental illnesses exact a staggering toll on millions of individuals, as well as on their families and communities and our Nation as a whole. Appropriate treatment can alleviate, if not cure, the symptoms and associated disability of mental illness. With proper treatment, the majority of people with mental illness can return to productive and engaging lives. There is no one size fits all treatment; rather, people can choose the type of treatment that best suits them from the diverse forms of treatment that exist. The main findings of the report, gleaned from an exhaustive review of research, are that the efficacy of mental health treatments is well documented and a range of treatments exists for most mental disorders. On the strength of these findings, the single, explicit recommendation of the report is to seek help if you have a mental health problem or think you have symptoms of a mental disorder. Today, the majority of those who need mental health treatment do not seek it. The reluctance of Americans to seek and obtain care for mental illness is all too understandable, given the many barriers that stand in their way. If the information contained in this Surgeon Generals report is to be translated into its recommended actionto seek help for mental ill nessour society must resolve to dismantle barriers to seeking help that are sizable and significant, but not insurmountable. This vision for the future proposes to the American people broad courses of action meant to hasten progress toward the major recommendation of this report. These calls to action constitute necessary first steps toward overcoming the gaps in what is known and removing the barriers that keep people from seeking and obtaining mental health treatment. Although these are not formal policy recommendations, they offer a focused vision that may inform future policy. They are intended for policymakers, service and treatment providers, professional and advocacy organizations, researchers, and, most importantly, the American people. The health of the American people demands that we act with resolve and a sense of urgency to place mental health as a cornerstone of health and address through research and education both the impact and the stigma attached to mental illness.
Special effort is required to address pronounced gaps in the mental health knowledge base. Key among these are the urgent need for research evidence that supports strategies for mental health promotion and illness prevention. Each chapter in this report has identified additional, specific gaps that must be addressed. The vitality of clinical research hinges on the willing participation of clinical research volunteers. By law, subjects in federally sponsored research are required to give informed consentthat is, to agree to participate voluntarily after being informed about the purpose, benefits, and risks of the research, among other requirements (45 CFR 46). The law affords special protections for children and for persons with impaired decisionmaking capacity. Policies must be promulgated to ensure that vulnerable individuals are protected while they participate in research needed for the development of new treatments. Overcome Stigma For our Nation to reduce the burden of mental illness, to improve access to care, and to achieve urgently needed knowledge about the brain, mind, and behavior, stigma must no longer be tolerated. The issuance of this Surgeon Generals Report on Mental Health seeks to help reduce stigma by dispelling myths about mental illness and by providing accurate knowledge to ensure more informed consumers. Organizations and individuals are encouraged to draw freely upon the report in their own efforts to combat the insidious effects of stigma. Improve Public Awareness of Effective Treatment Individuals should be encouraged to seek help from any source in which they have confidence. If they do not improve with the help obtained initially, they should be encouraged to keep trying to obtain assistance. If the path of help-seeking leads to only limited improvement, an array of options still exists: the intensity of treatment may be changed, new treatments may be introduced, or another provider may be sought. Family members, clergy, and friends often can help by encouraging a distressed person to seek help. All human services professionals, not just health professionals, have an obligation to be better informed about mental health treatment resources in their communities. Managed care companies and other health insurers need to publish clear information about their mental health benefits (usually called behavioral health benefits). At present, many beneficiaries appear not to know if they have mental health coverage, much less where to seek help for problems. Ensure the Supply of Mental Health Services and Providers Across the Nation, certain mental health services are in consistently short supply. These include the following: Wraparound services for children with serious emotional problems and multisystemic treatment. Both treatment strategies should actively involve the participation of the multiple health, social service, educational, and other community resources that play a role in ensuring the health and well-being of children and their families; The supply of well-trained mental health professionals also is inadequate in many areas of the country, especially in rural areas (Peterson et al., 1998). Particularly keen shortages are found in the numbers of mental health professionals serving children and adolescents with serious mental disorders and older people (Peterson et al., 1998). More mental health professionals also need to be trained in cognitive-behavioral therapy and interpersonal therapy, two forms of psychotherapy shown by rigorous research to be effective for many types of mental disorders. Ensure Delivery of State-of-the-Art Treatments Multiple and complex explanations exist for the gap between what is known through research and what is actually practiced in customary care. Foremost among these are practitioners lack of knowledge of research results; the lag time between the reporting of research results and the translation of new knowledge into practice; and the cost of introducing innovations in health systems. In addition, significant differences that exist between academic research settings and actual practice settings help account for the gap between what is known and what is practiced. The patients in actual practice are more heterogeneous in terms of their overall health and cultural backgrounds, and both patients and providers are subject to cost pressures. New strategies must be devised to bridge the gap between research and practice (National Advisory Mental Health Council, 1998). Tailor Treatment to Age, Gender, Race, and Culture To be effective, the diagnosis and treatment of mental illness must be tailored to individual circumstances, while taking into account, age, gender, race, and culture and other characteristics that shape a persons image and identity. Services that take these demographic factors into consideration have the greatest chance of engaging people in treatment, keeping them in treatment, and helping them to recover thereafter. The successful experiences of individual patients will positively influence attitudes toward mental health services and service providers, thus encouraging others who may share similar concerns or interests to seek help. While women and men experience mental disorders at almost equal rates, some mental disorders such as depression, panic disorder, and eating disorders affect women disproportionately. The mental health service system should be tailored to focus on womens unique needs (Blumenthal, 1994). Members of racial and ethnic minority groups account for an increasing proportion of the Nations population. Mental illness is at least as prevalent among racial and ethnic minorities as in the majority white population (Regier et al., 1993). Yet many racial and ethnic minority group members find the organized mental health system to be uninformed about cultural context and, thus, unresponsive and/or irrelevant. It is partly for this reason that minority group members overall are less inclined than whites to seek treatment (Sussman et al., 1987; Gallo et al., 1995), and to use outpatient treatment services to a much lesser extent than do non-Hispanic whites. Yet it is important to acknowledge and appreciate that there exist wide variations within and among racial and ethnic minority groups with respect to use of mental health services. The use of inpatient treatment services by African Americans, for example, is much higher than use of these services by whites, a difference that cannot be accounted for by differences in prevalence alone (Chapter 2). The reasons for these disparities in utilization of services must be further understood through research. In the interim, culturally competent servicesthat is, services that incorporate understanding of racial and ethnic groups, their histories, traditions, beliefs, and value systemsare needed to enhance the appropriate use of services and effectiveness of treatments for ethnic and racial minority consumers. With appropriate training and a fundamental respect for clients, any mental health professional can provide culturally competent services that reflect sensitivity to individual differences and, at the same time, assign validity to an individuals group identity. Still, many members of ethnic and racial minority groups may prefer to be treated by mental health professionals of similar background. There is an insufficient number of mental health professionals from racial and ethnic minority groups (Peterson et al., 1998), a problem that needs to be corrected. Facilitate Entry Into Treatment It is essential for first-line contacts in the community to recognize mental illness and mental health problems, to respond sensitively, to know what resources exist, and to make proper referrals and/or to address problems effectively themselves. For the general public, primary care represents a prime opportunity to obtain mental health treatment or an appropriate referral. Yet primary health care providers vary in their capacity to recognize and manage mental health problems. Many highly committed primary care providers do not know referral sources or do not have the time to help their patients find services. Some people do not seek treatment because they are fearful of being forced to accept treatments not of their choice or of being treated involuntarily for prolonged periods (Sussman et al., 1987; Monahan et al., 1999). For most, these fears are unwarranted: coercion, or involuntary treatment, is restricted by law only to those who pose a direct threat of danger to themselves or others or, in some instances, who demonstrate a grave disability. Coercion takes the form of involuntary commitment to a hospital; in about 40 states and territories, it includes certain outpatient treatment requirements. Advocates for people with mental illness hold divergent views regarding coercion. Some advocates crusade for more stringent controls and treatment mandates, whereas others adamantly oppose coercion on any grounds. One point is clear: the need for coercion should be reduced significantly when adequate services are readily accessible to individuals with severe mental disorders who pose a threat of danger to themselves or others (Policy Research Associates, 1998). As the debate continues, more study is needed concerning the effectiveness of different strategies to enhance compliance with treatment. Almost all agree that coercion should not be a substitute for effective care that is sought voluntarily. Reduce Financial Barriers to Treatment Recent legislative efforts to mandate equitable insurance coverage for mental health services have been heralded as steps in the right direction for reducing financial barriers to treatment. Still, for the more than 44 million Americans who lack any health insurance, equity of mental health and other health benefits is moot. For many who do have health insurance, coverage restrictions for mental health treatment persist. Data reveal that access to and use of services have increased following enhancements of mental health benefits in private insurance, Medicare, Medicaid, and the Federal Employees Health Benefit Program. Chapter 6 of this report makes it clear that equality between mental health coverage and other health coveragea concept known as parityis an affordable and effective objective. In states in which legislation requires parity of mental health and general coverage, cost increases are nearly imperceptible as long as the care is managed. A recent paper suggests that the value of mental health treatment has increased in recent yearsthat is, effectiveness has increasedwhile expenditures have fallen (Frank et al., 1999). In light of cost-containment strategies of managed care, concerns about undertreatment still are warranted for individuals with the most severe mental disorders, but high-quality managed care has the potential to effectively match services to patient needs. |