The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999. David Satcher, then the reigning surgeon general, emphasized the importance of adopting a national mental health agenda that acknowledges the effect that mental illness has on public health. He encouraged the general population to acknowledge that that mental illness is both disabling to the individual and costly to the public health system as a whole. He advocated for increased use of differential diagnosis by emphasizing the concept that both mental health and mental illness are “points on a continuum.” David Satcher charged us as a profession with reducing and eliminating the stigma associated with mental illness. He also highlighted the importance of a solid research base to evaluate the practicality and effectiveness of new approaches and overall accountability to the individuals for whom the interventions are intended. Satcher’s submission represents a blueprint for change. It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”
State of the Mental Health Union
The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999. David Satcher, (now former) Surgeon General of the United States, emphasized the importance of adopting a public health perspective, accepting that mental disorders are disabling, and seeing both mental health and mental illness as points on a continuum. (U.S. Department of Health and Human Services, 1999) He highlighted overarching themes of reducing and eliminating the stigma associated with mental illness, the importance of a solid research base to evaluate the practicality and effectiveness of new approaches, and overall accountability to the individuals for whom and intervention is intended. (Satcher, 2000) Satcher’s submission represents a blueprint for change. It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”
The foundation of Satcher’s public health perspective was rooted in the concept of preventive interventions. Since 1999 we have made significant progress in developing family-focused preventative interventions (Redmond, Spoth, Shin, & Lepper, 1999) including mother and mother-child programs for children of divorce (Wolchik et al., 2000). We have adopted an early intervention strategy and attempted to focus our preventative efforts on the individuals who have the most to gain/lose, children. Preventative efforts focused on coping with anger and stress, family bereavement, bullying, early conduct disorder, social relations, stress inoculation, and suicide prevention are yielding significant results among school-aged children. (Greenberg, Domitrovich, & Bumbarger, 2001; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006; Weissberg, Kumpfer, & Seligman, 2003) The underlying theory of many, if not most, of these research efforts is that “prevention programs enhance children’s socio-emotional competence and prevent the emergence of behavior problems.” (Webster-Stratton, 2003)
Although research suggests that there are correlates of life satisfaction in those with disabling conditions, much of the work has been focused on physical disabilities as opposed to mental illness. (Mehnert, Krauss, Nadler, & Boyd, 1990; Schröder et al., 2007) More work remains to be done regarding overall public awareness of exactly how debilitating mental illness can be. This is particularly true in the cases where individuals whom are heavily medicated may be more disabled by their medication than by the mental illness itself. (Waldman, 1999)
If we consider seeing mental health and mental illness as points on a continuum a goal, then we should consider ourselves closer to that goal then we were 10 years ago. (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000) Differential diagnosis is more prominent in the DSM-IV-TR than it was in any previous revision of the DSM, and we have every expectation that we will continue to see movement towards continuum based differential diagnosis in the upcoming DSM-V. As a profession, we can expect that the differentiation between normal psychological functioning and pathological functioning will continue to be defined, or redefined. (Widiger & Clark, 2000) We can expect that diagnostic categories be removed, added, merged, linked, or otherwise cross referenced to reflect the “points on a continuum” perspective. If I could predict the specific changes we should expect I wouldn’t be here, but I can be fairly certain that we should expect change in general.
Reducing and eliminating the stigma associated with mental illness is a tall order that is constantly in the process of fulfillment. Despite persistent efforts, anti-stigma campaigns have not yet resulted in the desired changes in public attitudes and perceptions. (McNulty, 2004) “Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care.” (Corrigan, 2004, p. 614) The availability of accurate information, persistent social marketing, and direct contact with the mentally ill can effectively combat the negative stereotypes associated with individuals who suffer from mental illness. (Kirkwood & Hudnall, 2006) Nonetheless, there is much work to be done… it is certainly a work in progress. Furthermore, the DSM has made an effort to reduce stigma by changing verbiage. For example, people who suffer from alcoholism are no longer referred to as “alcoholics” in an effort to focus on the disease, not the deficiency of the individual.
Nowhere have we made more progress than in the arena of developing a solid research base. Never before in human history have individual clinicians had access to the depth, breadth, and quality of research that we have today. This is due, in large part, to technology and the advent of reference-able online material. Scholars are no longer required to scour books at the library in search of support… we simply find a keyword and plug it into resources like Google, ProQuest, PsycARTICLES, WilsonWeb, ERIC or MEDLINE. The efficient dissemination of information is critical to our success as a mental health community because it prevents duplicate research efforts. It also provides instant access to research that can justify both diagnosis and treatment modalities.
We have also made significant progress in the form of accountability. Federal and state regulatory authorities are constantly reviewing, revising, and reinforcing quality control practices with regard to education and credentialing of mental health professionals. (Nelson, 2007) Despite the fact that outcome evaluation programs are becoming more common with regard to child welfare services, they are still lacking in the field of mental health as a whole. (Wall et al., 2005) Informed consent is now mandatory in most states, although there is a definitive lack of consistency in terms of what that informed consent document should contain, or how clearly it should be worded. (Walfish & Ducey, 2007)
There’s more work to be done, so the progress doesn’t stop here. Our profession is currently being assaulted by rigorous cost control efforts in the form of managed care. Increasingly, insurance companies are making the decision what is best for clients, not their caregivers… or, if the caregivers do weigh in on the decision, it is with the constraints of a limited number of sessions or available treatments. Although we have made considerable progress on a number of fronts, including information dissemination, accountability efforts, reducing stigmas, and prevention… all of these avenues of progress will need continued emphasis into the 22nd century in order to have a lasting effect on the profession as a whole.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Corrigan, P. (2004, Oct). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi: 10.1037/0003-066X.59.7.614
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