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Contact Us Spring 2001; Volume 2, Number 1
Health Highlights
 
Current Issues in Mental Health Policy
Colleen Barry
page 1 | page 2 | endnotes

The Surgeon General's report on mental health released in December 1999 alerted policymakers and the public to both the impact of mental illnesses on society and the swift pace of technological progress toward improving the health and well-being of individuals suffering from mental disorders.

Released in December 1999, Mental Health: A Report of the Surgeon General analyzes and reports on the central findings of a vast body of scientific literature concerning the diagnosis and treatment of mental illnesses. Dating back to its first report on the hazards of smoking in 1964, the Surgeon General's office has been responsible for assessing the state of the literature on vital public health concerns and making judgments about the weight of evidence on the efficacy of health interventions and treatments.

Prevalence and Access to Care

The Surgeon General's report stresses that mental disorders are health conditions with clinically and economically devastating effects for both individuals and families. Researchers estimated that the indirect costs of mental illness represented a $79 billion loss to the U.S. economy in 1990.1 This estimate primarily reflects morbidity costs in terms of lost productivity ($63 billion), but also includes mortality costs due to premature death ($12 billion), as well as productivity losses for incarcerated individuals and caregiver family members ($4 billion).

In a given year, about 19% of the U.S. population has a diagnosable mental disorder, 3% have co-morbid mental and addictive disorders, and 6% have addictive disorders alone. 2 Mental and addictive disorders are substantially under-treated. According to the report, about 15% of the adult population use mental health services in any given year. Approximately half of the individuals using mental health services (8%) have a specific mental or addictive disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-IIIR).3 Therefore, as the Surgeon General's report notes, less than one-third of adults with a diagnosable mental disorder receive treatment.4

Untreated mental disorders can lead to a loss of productivity, familial disruptions, significant personal distress, and disability. According to the Global Burden of Disease Study conducted for the World Health Organization and the World Bank, four of the 10 leading causes of disability for persons age 5 and older are mental illnesses.5 In the U.S., major depression is currently the leading cause of disability. Anxiety and mood disorders are the most prevalent diagnoses.6 The prevalence of anxiety disorders among adults ages 18 to 54 is over 16%, and the prevalence of mood disorders such as depression is about 7%.7 In contrast, schizophrenia affects only about 1% of the population.8

Efficacy of Treatments for Mental Disorders

The evidence in the Surgeon General's report suggests that a range of efficacious treatments exists for most mental disorders. The report highlights the extraordinary pace and productivity of scientific research on the etiology and treatment of mental illness with particular focus on the brain and behavior. Significant gains in pharmaceutical technology have led to the development of a more effective range of treatment therapies with fewer problematic negative side effects. Both the pace of medical discovery and faster approvals of new drugs in recent years by the FDA have contributed to the increasing use of these therapies. Various psychotherapies, such as psychodynamic, interpersonal, and cognitive-behavioral therapy, are also available. While treatment falls into two general categories, psychosocial and pharmacological, combined usage of the two (multi-modal therapy) can often prove more effective for individual patients.

Spending on Mental Health Care

National expenditures for the treatment of mental health and substance abuse (MH/SA) in 1997 totaled $82.2 billion, with 86% ($70.8 billion) spent on treating mental illness and 14% ($11.4 billion) spent on substance abuse.9, 10 MH/SA expenditures constitute about 7.8% of the more than one trillion dollars that constitute all U.S. health expenditures in 1997.11 Specialty mental health providers received 71% of total MH/SA expenditures, while general health care providers received 14.3%.12 The remaining 15% covered prescription drug costs (the fastest growing component of mental health expenditures) and administrative expenses of insurers.13

Mental health care spending grew more slowly than overall health expenditures over the last decade. While real health care spending grew by 5% annually between 1987 and 1997, real mental health spending grew by only 3.7%.14 Notably, these trends are reversed for prescription drug spending. The annual 9.3% inflation-adjusted increase in spending for prescription drugs to treat mental illness exceeds the annual 8.3% increase in spending on drugs for all health-related diagnoses.15

The primary explanation for lower relative growth in overall MH/SA spending is the reduction in hospital expenditures. The shift to managed care and price competition among health plans explains much of the reduction in hospital spending. According to the Surgeon General's report, about 72% of Americans with insurance were enrolled in managed behavioral health care in 1999.16 Similarly, enrollment in behavioral health carve-outs has grown over the decade. A recent survey of 50 large HMOs reports that about half of HMO enrollees were enrolled in carve-out plans.17 Research suggests that mental health may have been subject to more rigorous managed care cost control methods compared to the health care industry as a whole.18 It remains unclear whether restrained mental health spending signals erosion of insurance benefits and greater barriers to access or increased treatment cost-effectiveness.

Delivery of Mental Health Care

The Surgeon General's report also reviews the striking changes in the delivery of mental health care over the past few decades. Fifty years ago, a majority of those receiving care for mental disorders received treatment from a specialty provider in an inpatient setting. Today, an overwhelming proportion of individuals receiving mental health treatment get care on an outpatient basis. Of the 1.7 million psychiatric patient-care episodes in 1955, 77% were in 24-hour hospital services and 23% were in less than 24-hour services. By 1994, of the nearly 10 million episodes, 26% were in 24-hour hospital services and 74% were in less than 24-hour hospital services.19 Given the complexity and multiple funding sources of the contemporary U.S. mental health system, a primary challenge involves coordinating care and disseminating evidence on treatment efficacy across the continuum of service settings.

Role of the Public Sector

Federal, state, and local governments contribute substantially to the financing and delivery of mental health care. Public payers funded 58% of MH/SA spending in 1997, a much larger share than the 46% of total health expenditures paid for through the public sector.20 Historically, state and local governments have assumed a particularly large role in financing mental health services. In 1997, state and local governments provided 28% of all MH/SA expenditures, while funding only about 13% of health care services overall.21

In recent years, the federal government has increased its role in financing these services. Expenditures through the Medicaid and Medicare programs constitute 35 and 21%, respectively, of total public sector expenditures on mental health services.22 In addition to Medicare and Medicaid, the federal government provides additional resources through various programs including the Community Mental Health Block Grant, Community Support programs, the PATH program for services to the homeless mentally ill, and Comprehensive Community Mental Health Services for Children.

Stigma and Discrimination

The Surgeon General's report emphasizes the importance of changing public attitudes to eliminate the stigma associated with mental illness. Advocates for the mentally ill view stigma and discrimination as major impediments to the identification and successful treatment of mental disorders. Perceived stigma related to mental illness prevents individuals from acknowledging and seeking treatment for these conditions. Furthermore, stigma erodes public confidence that mental disorders are treatable. One major survey indicates that a plurality of Americans believe that mental illnesses are just like any other illness; however, 25% of survey respondents would not welcome facilities that treat or house people with mental illnesses into their neighborhoods, suggesting that some level of lingering stigma persists.23 The Surgeon General's report views increasingly effective treatments for mental disorders as the most potent long-range antidote to stigma, noting that "effective interventions help people to understand that mental disorders are not character flaws but are legitimate illnesses that respond to specific treatments, just as other health conditions respond to medical interventions."24

page 1 | page 2 | endnotes
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