Mental Health: A Report of the Surgeon General

Introduction to Range of Treatments
Psychotherapy
- Psychodynamic Therapy
- Behavioral Therapy
- Humanistic Therapy
Pharmacological Therapies
- Mechanisms of Action
- Complementary and Alternative Treatment
Issues in Treatment
- Placebo Response
- Benefits and Risks
- Gap Between Efficacy and Effectiveness
- Barriers to Seeking Help

Overview of Mental Health Services

Overview of Cultural Diversity and Mental Health Services

Introduction to Cultural Diversity and Demographics
- Coping Styles
Family and Community as Resources
- Epidemiology and Utilization of Services
- African Americans
- Asian/Pacific Islanders
- Hispanic Americans
- Native Americans
Barriers to the Receipt of Treatment
- Help-Seeking Behavior
- Mistrust
- Stigma
- Cost
- Clinician Bias
Improving Treatment for Minority Groups
- Ethnopsychopharmacology
- Minority-Oriented Services
- Cultural Competence
Rural Mental Health Services

Overview of Consumer and Family Movements

Origins and Goals of Consumer Groups
- Self-Help Groups
Accomplishments of Consumer Organizations
Family Advocacy

Overview of Recovery

Conclusions

Mental Health and Mental Illness Across the Lifespan

References

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Chapter 3
Children and Mental Health

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Normal Development

Theories of Development
- Development Viewed as a Series of Stages
- Intellectual Development
- Behavioral Development
Social and Language Development
- Parent-Child Relationships
- Origins of Language
- Relationships With Other Children
Temperament
Developmental Psychopathology
- Current Developmental Theory Applied to Child Mental Health and Illness

Overview of Risk Factors and Prevention

Risk Factors
- Biological Influences on Mental Disorders
- Psychosocial Risk Factors
- Family and Genetic Risk Factors
- Effects of Parental Depression
- Stressful Life Events
- Childhood Maltreatment
- Peer and Sibling Influences
- Correlations and Interactions Among Risk Factors
Prevention
- Project Head Start
- Carolina Abecedarian Project
- Infant Health and Development Program
- Elmira Prenatal/Early Infancy Project
- Primary Mental Health Project
- Other Prevention Programs and Strategies

Overview of Mental Disorders in Children

General Categories of Mental Disorders of Children
Assessment and Diagnosis
Evaluation Process
Treatment Strategies
- Psychotherapy
- Psychopharmacology

Attention-Deficit/Hyperactivity Disorder

Prevalence
Causes

Treatment
- Pharmacological Treatment
  - Psychostimulants
  - Dosing
  - Side Effects
  - Other Medications
- Psychosocial Treatment
  - Behavioral Approaches
  - Cognitive-Behavioral Therapy
  - Psychoeducation
- Multimodal Treatments
- Treatment Controversies
  - Overprescription of Stimulants
  - Safety of Long-Term Stimulant Use

Depression and Suicide in Children and Adolescents

Conditions Associated With Depression
Prevalence
- Major Depression
- Dysthymic Disorder
- Suicide
Course and Natural History
Causes
- Family and Genetic Factors
- Gender Differences
- Biological Factors
- Cognitive Factors
- Risk Factors for Suicide and Suicidal Behavior
Consequences
Treatment
- Depression
  - Psychosocial Interventions
  - Pharmacological Treatment
- Bipolar Disorder
  - Pharmacological Treatment
- Suicide
  - Psychotherapeutic Treatments
  - Psychopharmacological Treatments
  - Intervention After a Suicidal Death of a Relative, Friend, or Acquaintance
  - Community-Based Suicide Prevention
  - Crisis Hotlines
  - Method Restriction
  - Media Counseling
  - Indirect Case-Finding Through Education
  - Direct Case-Finding
  - Aggressive Treatment of Mood Disorders
  - Air Force Suicide Prevention Program—A Community Approach

Other Mental Disorders in Children and Adolescents

Anxiety Disorders
- Separation Anxiety Disorder
- Generalized Anxiety Disorder
- Social Phobia
- Treatment of Anxiety
- Obsessive-Compulsive Disorder
Autism
- Treatment
Disruptive Disorders
- Treatment
Substance Use Disorders in Adolescents
Eating Disorders

Services Interventions

Treatment Interventions
- Outpatient Treatment
- Partial Hospitalization/Day Treatment
- Residential Treatment Centers
- Inpatient Treatment
Newer Community-Based Interventions
- Case Management
  - Team Approaches to Case Management
- Home-Based Services
  - Family Preservation Programs Under the Child Welfare System
  - Multisystemic Therapy
- Therapeutic Foster Care
- Therapeutic Group Homes
Crisis Services

Service Delivery

Service Utilization
- Utilization in Relation to Need
- Early Termination of Treatment
- Poverty and Utilization
- Culture and Utilization
Service Systems and Financing
- Private Sector
- Public Sector
- Children Served by the Public Sector
- Managed Care in the Public Sector
Culturally Appropriate Social Support Services
Support and Assistance for Families
- New Roles for Families in Systems of Care
- Family Support
- Family Support Groups
- Practical Support
Integrated System Model
Effectiveness of Systems of Care
- The Fort Bragg Study
- The Stark County Study
Summary: Effectiveness of Systems of Care

Conclusions

References

Chapter 4
Adults and Mental Health

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Chapter Overview

Mental Health in Adulthood
- Personality Traits
  - Self-Esteem
  - Neuroticism
  - Avoidance
  - Impulsivity
  - Sociopathy
Stressful Life Events
- Past Trauma and Child Sexual Abuse
- Domestic Violence
- Interventions for Stressful Life Events
Prevention of Mental Disorders

Anxiety Disorders

Types of Anxiety Disorders
- Panic Attacks and Panic Disorder
- Agoraphobia
- Specific Phobias
- Social Phobia
- Generalized Anxiety Disorder
- Obsessive-Compulsive Disorder
- Acute and Post-Traumatic Stress Disorders
Etiology of Anxiety Disorders
- Acute Stress Response
- New Views About the Anatomical and Biochemical Basis of Anxiety
- Neurotransmitter Alterations
- Psychological Views of Anxiety
Treatment of Anxiety Disorders
- Counseling and Psychotherapy
- Pharmacotherapy
  - Benzodiazepines
  - Antidepressants
  - Buspirone
- Combinations of Psychotherapy and Pharmacotherapy

Mood Disorders

Complications and Comorbidities
- Clinical Depression Versus Normal Sadness
Assessment: Diagnosis and Syndrome Severity
- Major Depressive Disorder
- Dysthymia
- Bipolar Disorder
- Cyclothymia
- Differential Diagnosis
Etiology of Mood Disorders
- Biologic Factors in Depression Monoamine Hypothesis
- Evolving Views of Depression
- Anxiety and Depression
- Psychosocial and Genetic Factors in Depression
- Stressful Life Events
- Cognitive Factors
- Temperament and Personality
- Gender
- Genetic Factors in Depression and Bipolar Disorder
Treatment of Mood Disorders
- Stages of Therapy
  - Acute Phase Therapy
  - Continuation Phase Therapy
  - Maintenance Phase Therapies
Specific Treatments for Episodes of Depression and Mania
- Treatment of Major Depressive Episodes
  - Pharmacotherapies
  - Alternate Pharmacotherapies
  - Augmentation Strategies
  - Psychotherapy and Counseling
  - Bipolar Depression
  - Pharmacotherapy, Psychosocial Therapy, and Multimodal Therapy
  - Preventing Relapse of Major Depressive Episodes
- Treatment of Mania
  - Acute Phase Efficacy
  - Maintenance Treatment to Prevent Recurrences of Mania
- Service Delivery for Mood Disorders

Schizophrenia

Overview
- Cognitive Dysfunction
- Functional Impairment
- Cultural Variation
- Prevalence
  - Prevalence of Comorbid Medical Illness
Course and Recovery
- Gender and Age at Onset
Etiology of Schizophrenia
Interventions
- Pharmacotherapy
- Ethnopsychopharmacology
- Psychosocial Treatments
  - Psychotherapy
  - Family Interventions
  - Psychosocial Rehabilitation and Skills Development
  - Coping and Self-Monitoring
  - Vocational Rehabilitation

Service Delivery

Other Services And Supports

Consumer Self-Help
Consumer-Operated Programs
Consumer Advocacy
Family Self-Help
Family Advocacy
Human Services
- Housing
- Income, Education, and Employment
- Health Coverage
Integrating Service Systems

Conclusions

References

Chapter 5
Older Adults and Mental Health

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Chapter Overview

Overview of Mental Disorders in Older Adults

Assessment and Diagnosis
Overview of Prevention
- Primary Prevention
- Prevention of Depression and Suicide
- Treatment-Related Prevention
- Prevention of Excess Disability
- Prevention of Premature Institutionalization
Overview of Treatment
- Pharmacological Treatment
  - Increased Risk of Side Effects
  - Polypharmacy
- Treatment Compliance
- Psychosocial Interventions
- Gap Between Efficacy and Effectiveness

Depression in Older Adults

Diagnosis of Major and “Minor” Depression
- Late-Onset Depression
- Prevalence and Incidence
- Barriers to Diagnosis and Treatment
- Course
- Interactions With Somatic Illness
Consequences of Depression
Cost
Etiology of Late-Onset Depression
Treatment of Depression in Older Adults
- Pharmacological Treatment
  - Tricyclic Antidepressants
  - Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressants
  - Multimodal Therapy
  - Course of Treatment
- Electroconvulsive Therapy
- Psychosocial Treatment of Depression

Alzheimer’s Disease

Assessment and Diagnosis of Alzheimer’s Disease
- Mild Cognitive Impairment
- Behavioral Symptoms
- Course
- Prevalence and Incidence
- Cost
Etiology of Alzheimer’s Disease
- Biological Factors
Protective Factors
- Histopathology
- Role of Acetylcholine
Pharmacological Treatment of Alzheimer’s Disease
- Acetylcholinesterase Inhibitors
- Treatment of Behavioral Symptoms
Psychosocial Treatment of Alzheimer’s Disease Patients and Caregivers

Other Mental Disorders in Older Adults

Anxiety Disorders
- Prevalence of Anxiety
- Treatment of Anxiety
Schizophrenia in Late Life
- Prevalence and Cost
- Late-Onset Schizophrenia
- Course and Recovery
- Etiology of Late-Onset Schizophrenia
- Treatment of Schizophrenia in Late Life
Alcohol and Substance Use Disorders in Older Adults
- Epidemiology
  - Alcohol Abuse and Dependence
  - Misuse of Prescription and Over-the-Counter Medications
  - Illicit Drug Abuse and Dependence
- Course
- Treatment of Substance Abuse and Dependence

Service Delivery

Overview of Services
Service Settings and the New Landscape for Aging
- Primary Care
- Adult Day Centers and Other Community Care Settings
- Nursing Homes
- Services for Persons With Severe and Persistent Mental Disorders
Financing Services for Older Adults
- Increased Role of Managed Care
- Carved-In Mental Health Services for Older Adults
- Carved-Out Mental Health Services for Older Adults
- Outcomes Under Managed Care

Other Services and Supports

Conclusions

References

Chapter 6
Organizing and Financing
Mental Health Services

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Overview of the Current Service System

The Structure of the U.S. Mental Health Service System
The Public and Private Sectors
Patterns of Use
- Adults
- Children and Adolescents

The Costs of Mental Illness

Financing and Managing Mental Health Care

History of Financing and the Roots of Inequality
Goals for Mental Health Insurance Coverage
Patterns of Insurance Coverage for Mental Health Care
Traditional Insurance and the Dynamics of Cost Containment
Managed Care
- Major Types of Managed Care Plans
- The Ascent of Managed Care
Dynamics of Cost Controls in Managed Care
Managed Care Effects on Mental Health Services Access and Quality
Impact on Access to Services
Impact on Quality of Care

Toward Parity in Coverage of Mental Health Care

Conclusions

Appendix 6-A: Quality and Consumers’ Rights

References

Chapter 7
Confidentiality of Mental
Health Information: Ethical, Legal,
and Policy Issues

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Chapter Overview

Ethical Issues About Confidentiality

Values Underlying Confidentiality

Research on Confidentiality and Mental Health Treatment

Current State of Confidentiality Law

Overview of State Confidentiality Laws
Exceptions to Confidentiality
- Consent by the Person in Treatment
- Disclosure to the Client
- Disclosure to Other Providers
- Disclosure to Payers
- Disclosure of Information to Families
- Oversight and Public Health Reporting
- Research
- Disclosure to Law Enforcement Agencies
- Disclosure to Protect Third Parties

Federal Confidentiality Laws

Potential Problems With the Current Legal Framework

Summary

Conclusions

References

Chapter 8
A Vision for the Future

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Continue To Build the Science Base

Overcome Stigma

Improve Public Awareness of Effective Treatment

Ensure the Supply of Mental Health Services and Providers

Ensure Delivery of State-of-the-Art Treatments