Hopes and Challenges Moving Forward

The field of public mental health has seen many advances in policy and discovery, yet there is much more to be done. We must move beyond a narrow focus on clinical interventions to now embrace the impact of community and population dynamics in promoting mental health, preventing mental illnesses, and fostering recovery. We must take advantage of emerging technologies, tools and strategies to expand discovery of the causes of mental illness that will inform new prevention and treatment strategies. Emerging tools can also guide the best implementation of individual and systems-level changes. Finally, we must continue to monitor the frequency of illness and related outcomes among individuals and populations to gauge our progress and highlight areas for continued improvement.

Suicide as a Public Health Burden

This chapter reviews the burden associated with suicide in the United States and around the world as a leading cause of death. There are many factors associated with higher risk for suicide, and there are a range of conceptual approaches to understanding it, including the sociological perspective, originally proposed by Durkheim in the 19th century and elaborated in many ways since then. American Indians and Alaskan Natives; lesbian, gay, bisexual and transgender individuals; middle-aged men and women; and military personnel and veterans have higher than expected rates of suicide. Suicide sometimes occurs in imitation of public figures who take their own life, and the manner of journalistic reporting can affect the size of the imitative response in the population. Future directions for suicide prevention should focus on the need for data linkage and upstream approaches to identify novel predictors, evaluate the effectiveness of prevention techniques, and expand on prevention paradigms.

Community and Public Mental Health Services in the United States

This chapter reviews the history and current status of community behavioral health organizations (CBHOs) in the United States. The vast majority of individuals receiving behavioral health care today are served by outpatient community settings, with only a small proportion receiving care in inpatient facilities. This chapter provides an understanding of the vital role CBHOs play in providing both therapeutic and rehabilitative services to some of the nation’s most vulnerable citizens. It outlines the origins of CBHOs within the publicly funded health care system in the United States, provides examples of available programs and services, and delineates the range of challenges faced by contemporary CBHOs as they strive to meet the needs of people with serious mental illnesses.

The Burden of Mental Disorders

This chapter describes seventeen important mental disorders and reviews studies of the prevalence of the disorders from around the world, presenting median and interquartile ranges for more than four hundred research studies. The range of prevalences is below 0.5% for eating disorders and schizophrenia, and above 5% for attention deficit hyperactivity disorder, major depressive disorder, phobias, personality disorders, and dementia. The chapter discusses methods for judging the disability adjusted life years (DALYs) for the disorders and compares estimates to other diseases considered in the Global Burden of Disease study. Mental and substance use disorders account for more than 160 million of the total DALYs in the world, or about 7% of the total. Major depressive disorder is the leading causes of DALYs among the mental and substance use disorders.

Pathways to Care

This chapter discusses the gap between the need for mental health care and the actual receipt of such care, and the barriers that contribute to this gap. These barriers include attitudes such as stigma, negative attitudes about the benefits of mental health treatments, and lack of perceived need for care. Another set of barriers is related to the structure of services such as scarcity of providers, geographical distance, and inadequate health insurance coverage of mental health services. The chapter describes theoretical models used to understand the process of treatment-seeking and examples of initiatives that have been used to overcome barriers to care. Among these initiatives, public campaigns aimed at increasing awareness and recognition of mental disorders and at reducing stigma, and legislative initiatives aimed at increasing insurance coverage for mental health care have received public attention. Future initiatives to improve access to services and reduce the treatment gap would benefit from a better understanding of the process of treatment-seeking and barriers to mental health treatment.

Mental Health Systems Around the World

This chapter discusses the concepts, definitions, measurement instruments, and sources of data bearing on global mental health and mental illness. The discussion reveals the limited use of system-level instruments and readily comparable global data to help guide international public mental health policy. The chapter includes selected data on mental health systems around the world and gives an overview of mental health–related activities by leading international agencies such as the World Health Organization (WHO) Department of Mental Health and Substance Abuse, the United Nations Interagency Task Force (UNIATF) on the Prevention and Control of Non-communicable Diseases, the United Nations International Children’s Educational Fund (UNICEF), the United Nations High Commissioner for Refugees (UNHCR), and a range of international research consortia. The presence or absence of mental health policy, the presence of law relevant to mental health, and the presence of mental health care facilities around the world are reviewed.

Global Mental Health Issues

This chapter reviews cultural and contextual influences on the presentation and prevalence of mental health problems in low- and middle-income countries. “Culture” is defined as shared norms, beliefs, values, and attitudes, while “context” refers to resource availability and political/social situation. The chapter includes discussion of the local “emic” and universal “etic” approaches to understanding mental health and shows the ways in which cultural and contextual variation influences the understanding, presentation, and treatment of mental and behavioral disorders. Research on understanding the effects of culture on differences in diagnosis and prevalence of mental disorders, as well as processes of recovery, is reviewed as well as guidelines developed by the World Health Organization. The way in which cultural and contextual differences affect choice and implementation of treatment and prevention programs is discussed.

American Mental Health Services after the Affordable Care Act

This chapter examines American mental health services after the implementation of the Affordable Care Act (ACA). Diagnostic characteristics, health insurance coverage, and service use are analyzed for a synthetic sample of 100 adults pre and post ACA. Results document that an increased number of persons with mental illness had insurance coverage and service accessibility post ACA. The availability of service facilities and their use levels also are examined post ACA. A detailed national revenue and expenditure picture for mental health post ACA is derived from the National Health Accounts. Finally, the criminal justice sector is considered as an emerging site for service delivery.

Adult Mental Disorders in Association with Socioeconomic Position, Race/Ethnicity, and Sexual and Gender Minority Status

This chapter presents information about differences in risk for mood, anxiety, and substance use disorders across three demographic factors that are tied to social disadvantage: socioeconomic position, race/ethnicity, and sexual and gender minority status. It summarizes key results from studies of the general population, and presents information on prevalence and risk based on our analyses of national data sets. Systematic population subgroup differences exist. Persons in low socioeconomic position and sexual and gender minorities have higher odds of mental and behavioral disorders. Findings for racial/ethnic minorities were mixed. Although several studies showing that Black and Hispanic people have lower risk than Whites for mood, anxiety, and substance use disorders, research also shows that disorders among these groups are more severe and more persistent.

An Introduction to Quantitative Methods Relevant for Public Mental Health

This chapter provides a brief introduction to some of the epidemiologic and statistical methods for, and challenges to, gathering and analyzing the data that underlie the research presented in this volume and in the field of public mental health as a whole. The chapter is not intended as a general introduction to epidemiologic and statistical methods, but focuses more specifically on some of the data and methodological complexities particularly common in public mental health research. Three fundamental types of questions relevant to public mental health are discussed in particular: (1) estimating rates of disorders in a population across people, places, and time; (2) examining risk and protective factors associated with particular disorders; and (3) exploring and understanding the effects of interventions to prevent disorders or to treat them once they emerge.