# Cultural Sociology of Mental Illness: An A-to-Z Guide

Encyclopedias

### Edited by: Andrew Scull

• Entries A-Z
• Subject Index
• Front Matter
• Back Matter
• [0-9]
• A
• B
• C
• D
• E
• F
• G
• H
• I
• J
• K
• L
• M
• N
• O
• P
• Q
• R
• S
• T
• U
• V
• W
• X
• Y
• Z

Andrew Scull was born in Edinburgh, Scotland. He obtained his B.A. with first-class honors from Balliol College at the University of Oxford in politics, philosophy, and economics, and an M.A. and Ph.D. in sociology from Princeton University. From 1976 to 1977, he was a postdoctoral fellow in medical history at University College London. He has held faculty appointments at the University of Pennsylvania, Princeton University, and the University of California, San Diego, where he has been Distinguished Professor of Sociology and Science Studies since 1994.

Among others, he has held fellowships from the American Council of Learned Societies, the Guggenheim Foundation, and the Shelby Cullom Davis Center for Historical Studies at Princeton University, and he has served as director of a National Endowment for the Humanities Summer Seminar on “Madness and Society.” From 1992 to 1993, he was president of the Society for the Social History of Medicine.

Scull's work has been translated into Korean, Japanese, French, Spanish, Italian, and German. He has published more than 100 articles in leading journals in law, psychiatry, sociology, medical history, social history, neurology, and medicine. His many books include Decarceration (1977, 2nd ed. 1984); Museums of Madness: The Social Organization of Insanity in Nineteenth Century England (1979); The Most Solitary of Afflictions: Madness and Society in Britain, 1700–1900 (1993); Madhouse: A Tragic Tale of Megalomania and Modern Medicine (2005); and Hysteria (2009).

## List of Contributors

• Apryl Alexander

Florida Institute of Technology

• Joseph Daniel Anson

Florida State University

• Katherine L. Applegate

Duke University Medical Center

• Matthew E. Archibald

Colby College

• Steven Arenz

Winona State University

• Taj Artis

University of Southern California

• Aisha Asby

Prairie View A&M University

• Camela S. Barker

B and D Behavioral Health

• John H. Barnhill

Independent Scholar

• Kris Bevilacqua

Albert Einstein College of Medicine

• Shannon Bierma

University of Tennessee, Knoxville

• Thomas R. Blair

University of California, Los Angeles

• Bonnie Ellen Blustein

West Los Angeles College

• Dieter Bögenhold

• Sarah Boslaugh

Kennesaw State University

University of North Dakota

Saint Anselm College

• Hope Brasfield

University of Tennessee, Knoxville

• Joel Tupper Braslow

University of California, Los Angeles

• Candace S. Brown

Virginia Commonwealth University

• Lisa M. Brown

University of South Florida

• Rose Brown

University of North Carolina at Chapel Hill

• Vivienne Brunsden

Nottingham Trent University

• W. Jeff Bryson

Alabama Psychological Services Center

• Kathryn Burrows

Rutgers University

• Bonnie Burstow

Ontario Institute for Studies in Education

• Joan Busfield

University of Essex, Wivenhooe Park

• David Buxton

Harvard Massachusetts General Hospital

• Goldie Byrd

North Carolina A&T State University

• Paul Cantz

University of Illinois, Chicago College of Medicine

• Corey R. Carlson

Prairie View A&M University

• Erika Carr

Memphis VA Medical Center

• Roger J. Casey

VA National Center for Homelessness Among Veterans

• Tanya M. Cassidy

University of Windsor

Aneurin Bevan Health Board

• James J. Chriss

Cleveland State University

• Sarah Clement

King's College London

• Bruce Macfarlane Zarnovich Cohen

University of Auckland

• Justin Corfield

Independent Scholar

• Israel Cross

University of Maryland, Baltimore County

• Gareth Davey

Hong Kong Shue Yan University

• Fernando G. De Maio

DePaul University

• Tara DeBraber

University of Southern California

• Suzanne Delle

Salve Regina University

• Christina DeRoche

McMaster University

• Kendall Dodge

Elon University

• Sapna Doshi

Potomac Behavioral Solutions

• Nicholas R. Eaton

Stony Brook University

• Christopher L. Edwards

Duke University

• Joel P. Eigen

Franklin and Marshall College

• JoAnna Elmquist

University of Texas–Pan American

• Troy Ertelt

University of North Dakota

• Jeniimarie Febres

University of Tennessee, Knoxville

• Miriam Feliu

Duke University Medical Center

• Fabrice Fernandez

École des Hautes Études en Sciences Sociales

University of California, Los Angeles

• Steven L. Foy

Duke University

• Debra L. Frame

University of Cincinnati

• Julie L. Framingham

Florida Department of Children and Families

• Alexis T. Franzese

Elon University

• Ron Fritz

Independent Scholar

University of South Florida

• Dashiel Geyen

Texas Southern University

• Camille Gibson

Prairie View A&M University

• Brian Gifford

Integrated Benefits Institute

• Alyssa Gilston

University of the Rockies

• Jeffrey I. Goatcher

Nottingham Trent University

• Diane C. Gooding

• Robin Green

Albert Einstein College of Medicine

• Alyssa Gretak

Southern Illinois University, Edwardsville

• Natasha Gulati

Gonzaga University

• Jessica Smartt Gullion

Texas Woman's University

• Seth Donal Hannah

Harvard University

• Kathleen Harrison

Emmanuel College

• Tammy Hatfield

Lindsey Wilson College

• Julie Henderson

Flinders University

• Jason A. Helfer

Knox College

• Steven C. Hertler

College of New Rochelle

• LaBarron K. Hill

Duke University Medical Center

• Andrea Hobkirk

Duke University Medical Center

• Trina L. Hope

University of Oklahoma

• Allan V. Horwitz

Rutgers University

• James Edward Houston

Nottingham Trent University

• Andrew Hund

Umea University

• Alishia Huntoon

Oregon Institute of Technology

• Kathryn Hyer

University of South Florida

• David Ingleby

University of Amsterdam

• José R. Irizarry

Cambridge College

• Farah Islam

York University

• Kimberly Jinnett

Integrated Benefits Institute

• Deborah Johnson

University of California, San Francisco

• Laura Johnson

Chicago School of Professional Psychology

• Shama K. Kanwar

National Health Service

• Moira J. Kelly

Queen Mary University of London

• Alex Kertzner

University of California, Los Angeles

• Abigail Keys

Duke University

University of Tennessee, Knoxville

• Nazilla Khanlou

York University

• Katherine King

Duke University

• Eileen Klein

Ramapo College of New Jersey

• Virginia Elizabeth Klophaus

University of North Dakota

• Paul Komarek

Independent Scholar

• Sara Konrath

University of Michigan

• Ayelet Krieger

George Washington University

• Jennie Kronenfeld

Arizona State University

• Bill Kte'pi

Independent Scholar

• Lindsay Labrecque

Brown University

• Brenda A. LeFrancois

Memorial University of Newfoundland

• Samuel Lézé

École Normale Superieure de Lyon

• Lloyd L. Liang

Colby College

• Alisa Lincoln

Northeastern University

• Andrea Liner

George Washington University

• Samantha J. Lookatch

University of Tennessee, Knoxville

• Hector E. Lopez

Inter American University of Puerto Rico

• Kim Lorber

Ramapo College of New Jersey

• Marilyn D. Lovett

Livingstone College

• Meghan R. Lowery

Psychological Associates

George Mason University

• Sarah Mauck

University of Tennessee, Knoxville

• Melanie McCabe

North Carolina Central University

• Camela McDougald

B and D Behavioral Health

• Sally McManus

National Centre for Social Research

• Tara McMullen

University of Maryland, Baltimore County

• Marcia Meldrum

University of California, Los Angeles

• Katie Miller

University of North Dakota

• Shari Parsons Miller

Independent Scholar

• Lauren Mizock

Boston University

• Todd M. Moore

University of Tennessee, Knoxville

• Mary Beth Morrissey

Fordham Graduate School of Social Service

• Krysia N. Mossakowski

University of Hawai'i, Manoa

Elite Biobehavioral Health

Southern Illinois University, Edwardsville

• Andrew Ninnemann

Brown University

• Gerald E. Nissley, Jr.

East Texas Baptist University

• Vinai Norasakkunkit

Gonzaga University

• Keisha O'Garo

Yale University

• Lauren D. Olsen

University of California, San Diego

St. Francis Xavier University

• Erin Olufs

University of North Dakota

• Jamie L. Owens

University of Hawai'i, Manoa

• Yok-Fong Paat

University of Texas, El Paso

• Stephen D. Parker

University of Queensland

• Anna Patterson

Elon University

• Courtney Peasant

University of Memphis

• Lori Peek

• Georgina Perez

University of North Carolina at Chapel Hill

• Daniel W. Phillips III

Lindsey Wilson College

• Christopher Philo

University of Glasgow

• Ricardo Pietrobon

Duke University Medical Center

• Maribel Plasencia

Brown University

• Deborah A. Potter

University of Louisville

• Kelsey Price

Elon University

• Eve S. Puffer

Duke University

• Michael G. Rank

University of Southern California

• Gretchen M. Reevy

California State University, East Bay

• Kathrin Ritter

University of Tennessee, Knoxville

• Louise Roberts

Flinders University

• Christopher C. C. Rocchio

University of Hawai'i, Manoa

• Ward Rodriguez

California State University, East Bay

• Richard Lee Rogers

Youngstown State University

• Richard Ruth

George Washington University

• Stephanie Elias Sarabia

Ramapo College

• Jennifer C. Sarrett

Emory University

• Christine M. Sarteschi

Chatham University

• Anne-Maree Sawyer

La Trobe University

• Teresa L. Scheid

University of North Carolina, Charlotte

• Rob Schraff

University of California, Los Angeles

• Ariane Schratter

Maryville College

• Stephen T. Schroth

Knox College

• Joseph A. Scimecca

George Mason University

• Andrew Scull

University of California, San Diego

• Steven P. Segal

University of California, Berkeley

• John E. Senior

Linacre College, University of Oxford

• Holly Sevier

University of Hawai'i, Manoa

• Brent Mack Shea

Sweet Briar College

• David Shern

Mental Health America

• Ryan C. Shorey

University of Tennessee, Knoxville

• Dena T. Smith

Goucher College

• Kelly M. Smith

University of South Florida

• Leonard Smith

University of Birmingham

• Justin Snyder

Saint Francis University

• Wajma Soroor

York University

• Sally Spencer-Thomas

Carson J. Spencer Foundation

• Raja Staggers-Hakim

Eastern Connecticut State University

• Sarah M. Steverman

M. S. W. Catholic University

• Wendy Ellen Stock

Independent Scholar

• Victor B. Stolberg

Essex County College

• Joan Striebel

University of California, San Francisco

• Gregory L. Stuart

University of Tennessee, Knoxville

• Akihito Suzuki

Keio University

• Angela Sweeney

University College London

• Christine Tarleton

University of California, Los Angeles

• Samuel Terrazas

University of Texas at El Paso

• Garth Terry

University of California, Los Angeles

Duke University

• Eugenia Tsao

University of Toronto

• Emma Tseris

University of Sydney

University of Wisconsin, La Crosse

• Darci Van Dyke

University of North Dakota

• Shayna Vi

University of Hawai'i, Manoa

• Scott Alexander Vieira

Sam Houston State University

• Erin Voss

University of Southern California

• Bavna Bagyalakshmi Vyas

Independent Scholar

• Elaine Walsh

University of Washington

• Kira Walsh

Emory University

• Elizabeth A. Wangard

George Washington University

Metropolitan College of New York

• Jenny Weinstein

Kingston University

• Eugenia L. Weiss

University of Southern California

• Keith E. Whitfield

Duke University

• Rebecca Wilkinson

University of California, Los Angeles

• Veeda Williams

Prairie View A&M University

• Derek Wilson

Prairie View A&M University

• Sarah M. Wilson

Duke University

• Mark Wolfson

Wake Forest School of Medicine

• Mary Wood

Duke University Medical Center

• Vania Regina De Angeli Wood

North Carolina Central University

• Edward C. Wright

University of Texas Health Science Center, San Antonio

• Susan J. Wurtzburg

University of Hawai'i, Manoa

• Rebekah M. Zincavage

Brandeis University

• Heather Zucosky

University of Tennessee, Knoxville

## Introduction

Mental illness, as the eminent historian of psychiatry Michael MacDonald once aptly remarked, “is the most solitary of afflictions to the people who experience it; but it is the most social of maladies to those who observe its effects” (MacDonald 1981: 1). It is precisely the many social and cultural dimensions of mental illness that have made the subject of such compelling interest to sociologists.

This encyclopedia is testimony to the enormously wide social ramifications of mental illness and the inextricable ways in which the cultural and the social are implicated in what some might view as a purely intrapsychic phenomenon. Psychiatry has typically, though far from always, focused on the individual who suffers from various forms of mental disorder. For the sociologist, it is naturally the social aspects and implications of mental disturbance for the individual, their immediate interactional circle, the surrounding community, and society as a whole that have been the primary intellectual puzzles drawing attention.

How, for example, are we to define and draw boundaries around mental illness and distinguish it from eccentricity or mere idiosyncrasy, to draw the line between madness and malingering, mental disturbance and religious inspiration? Who has social warrant to make such decisions and why? Do such things vary temporally and cross-culturally? How have societies responded to the presence of those who do not seem to share commonsense notions of reality? Who embraces views of reality that strike others as delusional? Who sees objects and hears voices invisible and inaudible to the rest of us? Who commits heinous offenses against law and morality with seeming indifference? Or whose mental life seems so denuded and lacking in substance as to cast doubt on their status as autonomous human actors?

Mental illness has profoundly disruptive effects on individual lives and the social order we all take for granted. Erving Goffman, whose mid-20th-century writings still constitute some of the most provocative and profound sociological meditations on the subject, is perhaps best known for his searing critique of mental hospitals as total institutions and engines of degradation and destruction that falsely put on a medical gloss (Goffman 1961). But he also spoke eloquently of “the social significance of the confusion [the mental patient] creates,” arguing that it “may be as profound and basic as social existence can get.” He insisted, rightly in my view, that “mental symptoms are not, by and large, incidentally a social infraction. By and large, they are specifically and pointedly offensive. … It follows that if the patient persists in his [sic] symptomatic behavior, then he must create organizational havoc and havoc in the minds of members [of society].”

Characteristically, Goffman then proceeded to critique the response of our contemporary credentialed experts in the treatment of mental illness: “It is this havoc that psychiatrists have dismally failed to examine.” But he was equally scathing about many of his contemporaries in the sociological profession, who then sought to dismiss mental illness as a purely socially constructed category, a mere matter of labels. Sociologists who adopted this romantic view were equally guilty of playing down or ignoring the profoundly disruptive effects of madness on the individual and on society (Goffman 1971: 356–357).

Accepting the Concept of Mental Illness

Accepting, then, that there is such a thing as mental illness (all the while acknowledging that some sociologists and even some renegade psychiatrists have questioned its reality, and still others have debated its designation as a specifically medical problem), a whole series of further questions then arises: How much of it is there, and how do we know, if indeed we do? What is its social location? Does it differ by class, age, gender, race, ethnicity, and so forth? Do these social variables have implications for the way mental illness is reacted to and socially managed? What are the costs of such episodes of mental disturbance to individuals, families, and society as a whole, and how are those costs distributed? How have societies characteristically responded to mental illness, and what institutions have they constructed to contain and perhaps cure it? What changes in these responses have occurred over time, and what accounts for these changes? How has mental illness been conceptualized by professionals, but also by the laity? And how have these differing cultural meanings been captured, refracted, and distorted in popular culture? One could go on, and the body of this encyclopedia deals with an even broader array of sociologically relevant topics, but the vital importance of a sociological perspective on mental illness should by now be apparent.

Early Viewpoints

It should come as no surprise to learn that from the discipline's first days, many sociologists have had something to say about the subject. Sociology as a discipline began to coalesce in the late 19th and early 20th centuries in France, Britain, Germany, and the United States, at first often outside university settings, as in the British social survey tradition pioneered by Charles Booth (1889, 1891, and 1892–97) and Benjamin Seebohm Rowntree (1901), but soon enough within the walls of academic institutions. The earliest academic sociologists often secured niches in other disciplines; Émile Durkheim's first appointment at Bordeaux was in social science and pedagogy and his later chair at the Sorbonne was as professor of education. Max Weber's at Freiburg was in economics, as was his next appointment at Heidelberg, but soon enough the discipline managed to institutionalize itself as a separate and legitimate academic endeavor.

Durkheim played a critical role in this process in France and aggressively sought to claim for sociology a distinctive realm of social facts, external and constraining on the individual. Much of his work thus had an overtly polemical cast, and even the subject matter he chose was often influenced by its value in establishing the intellectual legitimacy of sociology and its status as a distinct and autonomous science as well as demonstrating the unique power of “the social” in the explanation of sociological phenomena. “Every time,” he boldly and wrongly proclaimed, “a social phenomenon is directly explained by a psychological phenomenon, we may rest assured that the explanation is false” (Durkheim 1895: 129).

Two years later, he deliberately chose an apparently quintessentially individual act—suicide—and attempted to account for it in social terms. More precisely, he claimed to detect in the statistics on suicide a whole series of distinct regularities, for which he proffered a sociological explanation (Durkheim 1897). Necessarily, he was thereby led to confront the question of insanity and its possible relationship to suicide—mental illness in both its most florid manifestations and in borderline examples of mental disturbance such as alcoholism and what was then called neurasthenia, or weakness of the nerves. To his own satisfaction, at least, Durkheim claimed to have shown that while all of these conditions might predispose an individual toward suicide, it was social factors rather than individual psychopathology that explained the rate at which people killed themselves.

To the extent that sociopsychological states led vulnerable people to commit suicide, those states were themselves the product of sociological factors; in modern societies, most commonly the condition he labeled “anomie,” or the failure of the social order to adequately regulate the beliefs and behaviors of its members. (For critiques of Durkheim's arguments, see H. W. Douglas 1967; S. M. Lukes 1973.)

The Chicago School

If Durkheim and the Durkheimian school dealt with mental illness only tangentially, another major school of sociological thought that was emerging in the early 20th century, the Chicago school, led by Robert Park and Ernest Burgess, frequently tackled the subject more directly. In important ways, the sociologists trained at the University of Chicago were heirs to the social survey tradition that had emerged in late 19th-century Britain. Park, Burgess, and their students treated the city as their laboratory and set forth to document its structures and its pathologies (Park, Burgess and R. McKenzie 1925).

Like their British predecessors, the Chicago sociologists employed both statistical techniques and ethnographic observation, both mapping the statistical distribution of social problems and providing detailed ethnographic studies of their place in specific neighborhoods in the city. Psychoses were only one of a number of what they termed social pathologies that fell under their gaze, alongside homelessness, alcoholism, suicide, homicide, prostitution, juvenile delinquency, and crime. Characteristically, the psychological disorganization that characterizes mental illness (and other forms of deviance) was linked to the social disorganization of particular communities—the prevalence of anonymous and transitory social relationships and the weakness of social ties, all associated with the breakdown of social controls. (For discussions of the Chicago School, see M. Bulmer 1984; R. E. L. Faris 1967.)

The culmination of this perspective on the sociological study of mental illness came with the 1939 publication of Robert E. Faris and Henry Warren Dunham's monograph Mental Disorders in Urban Areas, a volume that, its title notwithstanding, focused primarily on Chicago (See Faris and H. W. Dunham 1939; and for an attempt to generalize their findings to other cities, C. W. Schroeder 1942). But in a broader sense, the fascination with deviance that the Chicago school exhibited, and the preoccupation of many of the sociologists it trained with ethnographic approaches to the study of social life, can be traced in many of the works of postwar American sociology, not least many of the classic studies emerging in the 1950s and 1960s that were devoted to the sociology of mental illness.

Post–World War II Ideologies

World War II and its aftermath marked a turning point for American social science and for American universities more broadly. The mobilization of society for total war broke down the barriers—legal and ideological—to the expansion of central state powers, as well as finally vanquishing the Great Depression. The upshot was a vast increase in the size and reach of the American federal government, a development that proved permanent and has only accelerated in the years since. In war's shadow, there was little disposition to rein in the expanded scope of federal authority, and what resistance there was melted away with the outbreak of the Cold War in 1947.

Science, including social science, had played an enormous role in the war effort, and as the conflict drew to a close, efforts were made to rethink the role of science and society in the soon-to-be postwar world. The most notable instance of this new thinking was Vannevar Bush's extended memorandum to President Franklin D. Roosevelt, subsequently published as Science: The Endless Frontier (Bush 1945). Written by the wartime director of the Office of Scientific Research and Development, it presented a wide-ranging overview of the conditions of scientific research, its potential contributions to public welfare, the reconfigurations that would be necessary after the war, and the potential role of Washington, both in securing the training of scientific talent and in the prosecution of scientific research.

Though its primary remit was the natural sciences and medicine, it ranged broadly over its chosen terrain, and in the Harry S. Truman administration it would serve as the inspiration for the formation of the National Science Foundation and the National Institutes of Health, both of which would transform the environment for research and the nature of the modern university. The era of Big Science and the modern research university may be said to be its progeny. Where before the war, federal involvement in scientific and medical research—let alone the social sciences—had been vanishingly small, from the late 1940s onward and particularly since the Cold War, it started down the pathway of exponential growth that has continued ever since. With burgeoning federal investment, the process of knowledge creation and major characteristics of the academic world were irrevocably altered.

Military conflict had an even more direct impact on the psychiatric sector. Modern industrialized and mechanized warfare has repeatedly had drastic effects on the mental health of military personnel, and World War II, like the first, saw a massive number of psychiatric casualties spawned by the horrors of combat. Many of these were permanently harmed, so military authorities faced the immediate emergency of coping with soldiers breaking down—the effects on fighting efficiency and morale—and the postwar problems posed by disabled veterans with grave and continuing psychiatric problems. The exigencies of wartime prompted a massive expansion in the number of medics deployed to deal with psychiatric emergencies as well as a continuing, expanded demand for psychiatrists after the war ended. The knowledge that even the apparently psychiatrically healthy broke down in large numbers under enormous stress, combined with the heroic status of these psychiatric casualties, also helped change popular attitudes to mental illness and encouraged the psychiatric profession to believe that many cases of mental illness could be treated outside the walls of the traditional mental hospital (A. Scull 2010).

The National Institute of Mental Health

The consequences of this situation were many. Direct provision of mental health services remained a state rather than a federal responsibility, with the exception of a considerable increase in the number of veterans' hospitals devoted to providing psychiatric services. But both the Veterans Administration and the newly established National Institute of Mental Health (NIMH) were soon pouring funds into the training of mental health professionals, and NIMH also embarked on a program of basic research in the mental health sector. Within psychiatry, a rapid shift occurred in the locus of psychiatric practice as increasing numbers of professionals opted for the outpatient sector and traditional mental hospitals were left with the dregs of the profession. The number of psychiatrists rose rapidly, and for at least a quarter-century, the most ambitious among them for the most part embraced some version of Freudian psychoanalysis.

NIMH adopted an extremely broad definition of what constituted research relevant to its mission of understanding mental illness and improving its treatment. The bulk of its research funding was directed to the social sciences, not to psychiatry, in part because psychoanalysts spurned the sort of research the agency was willing to fund and in part because they were such inept grantsmen. Though the great bulk of social science funding went in turn to the discipline of psychology, a considerable fraction of federal money was captured by sociologists, and for the three decades after World War II, much of the flourishing state of the sociology of mental illness can be attributed to this flow of federal research dollars (Scull 2011a; 2011b).

Some of this work was conducted intramurally at the Laboratory of Socio-Environmental Studies, headed by sociologist John Clausen (1956), and at the Biometry branch, where the collection of systematic statistical data and the development of epidemiological research were encouraged. But much also took the form of NIMH training grants and extramural research grants. Substantively, much of the work in the 1950s built upon the intellectual foundations provided by the Chicago school in its dual emphasis on quantitative and ethnographic techniques. Large-scale studies of social class and mental illness, mental illness and the family, and popular conceptions of mental illness were undertaken and in some instances stretched over several decades. The centrality of the mental hospital in the mental health sector, both prewar and postwar, and the relevance of sociological perspectives for the understanding of these complex organizations meant that these too became a focus of much-funded research.

A Common Endeavor

In the early 1950s, much of this research was collaborative in nature, linking together psychiatrists or other mental health professionals and sociologists in a common endeavor. Notable examples include Alfred Stanton and Morris Schwartz's (1954) ethnography of the Chesnut Lodge private mental hospital and the work by August B. Hollingshead and Fredrick C. Redlich (1958) and their team of researchers on social class and family dynamics and mental illness (J. K. Myers and B. H. Roberts 1959; see also A. H. Leighton, J. A. Clausen and R. N. Wilson 1957; T. A. Rennie and L. Srole 1956; M. Greenblatt, D. J. Levinson, and R. H. Williams 1957; M. R. Yarrow, C. G. Schwartz, H. S. Murphy, and L. C. Deasy 1955). Soon, however, sociological work began to embrace a far more critical stance toward psychiatry and psychiatric institutions, a shift in intellectual perspective that emerged particularly strongly in studies of mental hospitals and institutional psychiatry.

The altered intellectual stance was evident as early as 1956, with the appearance of Ivan Belknap's study of a Texas mental hospital and its conclusion that “mental hospitals are probably themselves obstacles in the development of an effective plan of treatment for the mentally ill” so that “in the long run the abandonment of the state hospitals might be one of the greatest humanitarian reforms and the greatest financial economy ever achieved” (I. Belknap 1956: xi, 212). It is equally evident in such later works as Dunham and S. K. Weinberg (1960) and R. Perrucci (1974) and perhaps achieved its apotheosis in Erving Goffman's devastating portrait in 1957 of mental hospitals as “total institutions” was reprinted in his 1961 Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, which became one of the more enduring works of mid-20th-century American sociology (Goffman 1961).

Goffman was trained at Chicago, and his research for Asylums, undertaken while he was on staff at the NIHM Laboratory of Socio-Environmental Studies, included a year of fieldwork at St. Elizabeth's Mental Hospital in Washington, D.C. But while in one sense rooted in the Chicago school tradition, Goffman's work was in many ways Durkheimian in inspiration. In contrast to the symbolic-interactionist emphasis on the fluidity of social interaction, Goffman's is a portrait of structural determinism. Mental hospitals resemble prisons and concentration camps as well as monasteries, nunneries, and boarding schools.

Life in such places is a product of their structural features, and their defects are not removable by any conceivable sets of reforms. Instead, life in a mental hospital inexorably tends to damage, dehumanize, and destroy. Psychiatrists are ridiculed as members of a “tinkering trade” who induce their subordinates to stage elaborate rituals designed to show that they preside over a medical establishment devoted to humane care and cure, when in reality, they are little better than prison guards helping to generate the very pathologies they claim to treat. As Goffman put it a decade later, mental hospitals were no more than “hopeless storage dumps trimmed in psychiatric paper.” As for the patient, he has been duped, suffering “dislocation from civil life, alienation from loved ones who arranged for the commitment, mortification due to hospital regimentation and surveillance, permanent post-hospital stigmatization. This has not merely been a bad deal; it has been a grotesque one” (Goffman 1971: 390).

Differing Views

From the late 1960s through the 1980s, the intellectual distance and even hostility between sociologists and psychiatrists often seemed to be growing. Within five years of the appearance of Asylums, the California sociologist Thomas Scheff had authored an in some ways still more radical assault on psychiatry, dismissing the medical model of mental illness and attempting to replace it with a societal reaction model, wherein mental patients were portrayed as victims—victims, most obviously, of psychiatrists (Scheff 1966). Noting that despite centuries of effort, “there is no rigorous knowledge of the cause, cure, or even the symptoms of functional mental disorders,” he argued that we would be better off adopting “a [sociological] theory of mental disorder in which psychiatric symptoms are considered to be labeled violations of social norms, and stable ‘mental illness’ to be a social role” and “societal reaction [not internal pathology] is usually the most important determinant of entry into that role” (Scheff 1966: 7, 25, 28).

During the 1960s and 1970s, the societal reaction theory of deviance enjoyed a broad popularity and acceptance among many sociologists, and Scheff's was one of the principal works in that tradition. But besides attracting derision and hostility from psychiatrists (M. Roth 1973), where they deigned to notice his work at all, it came under increasing criticism from within sociology on both theoretical (D. Morgan 1975) and empirical (W. R. Gove 1970; Gove and P. Howell 1974) grounds. In the face of an avalanche of well-founded objections, Scheff was eventually forced to back away from many of his more extreme positions, and by the time the third edition of his book appeared (Scheff 1999), most of its bolder ideas had been quietly abandoned. Labeling and stigmatization of the mentally ill have remained important subjects for sociologists, even if few would now argue that they have the etiological significance once attributed to them.

Major Changes in the Past Half-Century

Though the skeptical claims of the labeling theorists have now been sharply curtailed, much of the sociological work being done on mental illness has retained its critical edge. Four major interrelated changes have occurred in the psychiatric sector in the past half-century or so: the progressive abandonment of the prior commitment to segregative responses to serious mental illness and the run-down of the state hospital sector; the collapse of psychoanalysis and its replacement by a renewed emphasis on the biological basis of mental illness; the psychopharmacological revolution; and the so-called neo-Kraepelinian revolution, the rise of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) to a position of overwhelming importance, not just to the practice of psychiatry in the United States but also to developments elsewhere in the world. Sociologists have played a crucial role in analyzing the sources and impact of most of these changes, and sociological perspectives have spread and been highly influential among others attempting to make sense of these profoundly important developments.

Deinstitutionalization, for example, was initially presented as a grand reform, ironically just as the mental hospital had originally been (D. Rothman 1971; Scull 1979, 1993). From the mid-1970s, however, a more skeptical set of perspectives emerged. Psychiatrists had assumed that the new generation of antipsychotic drugs had been the main drivers of the expulsion of state hospital patients. A series of studies demonstrated the fallacy of this claim (Scull 1976, 1977; P. Lerman 1982; W. Gronfein 1985a). Others sought alternative explanations of the shift in social policy, and a series of studies began to suggest some of the defects of the new approach to the management of chronic mental illness (S. A. Kirk and M. Thierren 1975; U. Aviram, S. I. Syme and J. B. Cohen 1976; C. Windle and D. Scully 1976; Scull 1977, 1984; S. Rose 1979; Gronfein 1985b). The hegemony of the DSM began to attract attention, with critics examining both the processes by which the successive editions had been produced and the intended and unintended effects of its widespread use (Kirk and H. Kutchins 1992; Kutchins and Kirk 1997; A. V. Horwitz and J. C. Wakefield 2007; 2012). The sources and impact of the psychopharmacological revolution drew increased interest, with attention paid to both the role of the pharmaceutical industry and changes in the intellectual orientation of the psychiatric profession (D. Healy 1997, 2002; D. Herzberg 2008).

All of this occurred in a context where much of the federal money that had once underwritten sociological work on mental illness had been sharply curtailed. In the 1960s and 1970s, NIMH continued to broadly define its research mission and fund an extensive array of psychological and sociological research. Subjected to political pressures to direct funding toward the solution of social problems, the agency underwrote a broad array of studies on such topics as crime, drug and alcohol addiction, suicide, and even rape—all topics of some relevance to mental health issues and all ensuring a continual flow of federal research money into the social sciences, but scarcely central concerns for those focused on psychiatric disorders.

During the 1980s, however, this pattern of research funding abruptly altered. The Republican administration elected in 1982 ordered NIMH to redirect its funding priorities away from social problem–oriented research toward work more directly pertinent to the understanding of mental disorders (L. C. Kolb, S. H. Frazier, and P. Sivrotka 2000). Simultaneously, the intellectual center of gravity within psychiatry was shifting decisively away from psychoanalysis and a biosocial model of mental disorder and toward a biologically reductionist view of mental illness. The social, so far as most psychiatrists were concerned, went from being directly relevant to being at best marginal to their research. Thus, political pressures to avoid controversial and sensitive work on the sociological dimensions of mental disorder were reinforced by the demands of psychiatry for an increased focus on neuroscience and psychopharmacological research.

Scholars working on the sociology of mental illness thus now confront a very different research environment than the one that prevailed a quarter century ago. The range of intellectual and policy issues thrown up by the dramatic changes that have marked the mental health sector in the same period mean, however, that there is an abundance of challenging topics for the study of which sociological perspectives are indispensable. The range and scope of this encyclopedia create a vivid testimony to the intellectual vitality of the field and will hopefully make a useful contribution to the next generation of sociological research on the cultural sociology of mental illness.

, , and . “The Effects of Policies and Programs on the Reduction of Mental Hospitalization.”Social Science and Medicine, v.10 (1976). http://dx.doi.org/10.1016/0037-7856%2876%2990027-5
Human Problems of the State Mental Hospital. New York: McGraw-Hill, 1956.
. Life and Labour of the People in London.
1st ed.
, vol. 1. London: Macmillan, 1889.
. Life and Labour of the People in London.
1st ed.
, vol. 2. London: Macmillan, 1891.
Life and Labour of the People in London.
2nd ed.
, 9 vols. London: Macmillan, 1892–97.
The Chicago School of Sociology. Chicago: University of Chicago Press, 1984.
Science: The Endless Frontier: A Report to the President. Washington, DC: U.S. Government Printing Office, 1945.
Sociology and the Field of Mental Health. New York: Russell Sage Foundation, 1956.
The Social Meanings of Suicide. Princeton: Princeton University Press, 1967.
and . The Culture of the State Mental Hospital. Detroit, MI: Wayne State University Press, 1960.
The Rules of Sociological Method. English trans. New York: Free Press, 1982.
Suicide. English trans. New York: Free Press, 1997.
Chicago Sociology: 1920–1932. San Francisco: Chandler, 1967.
and . Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses. Chicago: University of Chicago Press, 1939.
Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, NY: Doubleday, 1961.
“The Insanity of Place.”Psychiatry, v.32 (1971).
“Societal Reaction as an Explanation of Mental Illness: An Evaluation.”American Sociological Review, v.35 (1970). http://dx.doi.org/10.2307/2093298
and . “Individual Resources and Mental Hospitalization: A Comparison and Evaluation of the Societal Reaction and Psychiatric Perspectives.”American Sociological Review, v.39 (1974). http://dx.doi.org/10.2307/2094278
, , and . The Patient and the Mental Hospital. New York: Free Press, 1957.
“Incentives and Intentions in Mental Health Policy: A Comparison of the Medicaid and Community Mental Health Programs.”Journal of Health and Social Behavior, v.26 (1985). http://dx.doi.org/10.2307/2136752
“Psychotropic Drugs and the Origins of Deinstitutionalization.”Social Problems, v.32 (1985). http://dx.doi.org/10.2307/800774
The Antidepressant Era. Cambridge, MA: Harvard University Press, 1997.
The Creation of Psychopharmacology. Cambridge, MA: Harvard University Press, 2002.
Happy Pills in America: From Miltown to Prozac. Baltimore, MD: Johns Hopkins University Press, 2008.
and . Social Class and Mental Illness: A Community Study. New York: Wiley, 1958. http://dx.doi.org/10.1037/10645-000
Creating Mental Illness. Chicago: University of Chicago Press, 2003.
and . All We Have to Fear: Psychiatry's Transformation of Natural Anxieties Into Mental Disorders. New York: Oxford University Press, 2012.
and . The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. New York: Oxford University Press, 2007.
and . The Selling of DSM: The Rhetoric of Science in Psychiatry. New York: de Gruyter, 1992.
and . “Community Mental Health Myths and the Fate of Formerly Hospitalized Patients.”Psychiatry, v.38 (1975).
, , and . “The National Institute of Mental Health: Its Influence on Psychiatry and the Nation's Mental Health.” In American Psychiatry After the War, and , eds. Washington, DC: American Psychiatric Press, 2000.
and . Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York: Free Press, 1997.
, , and , eds. Explorations in Social Psychiatry. New York: Basic Books, 1957.
Deinstitutionalization and the Welfare State. New Brunswick, NJ: Rutgers University Press, 1982.
Émile Durkheim: His Life and Work: A Historical and Critical Study. London: Allen Lane, 1973.
Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth Century England. Cambridge: Cambridge University Press, 1981.
“Explaining Mental Illness.”European Journal of Sociology, v.16 (1975). http://dx.doi.org/10.1017/S000397560000494X
and . Family and Class Dynamics in Mental Illness. New York: Wiley, 1959.
, , and . The City. Chicago: University of Chicago Press, 1925.
Circle of Madness: On Being Insane and Institutionalized in America. Englewood Cliffs, NJ: Prentice-Hall, 1974.
and . “Social Class Prevalence and Distribution of Psychosomatic Conditions in an Urban Population.”Psychosomatic Medicine, v.18 (1956).
“”Deciphering Deinstitutionalization: Complexities in Policy and Analysis.”Milbank Memorial Fund Quarterly, v.57 (1979).
“Psychiatry and Its Critics.”British Journal of Psychiatry, v.122 (1973).
The Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston: Little, Brown, 1971.
Poverty: A Study of Town Life. New York: Macmillan, 1901.
Being Mentally Ill: A Sociological Theory. Chicago: Aldine, 1966.
Being Mentally Ill: A Sociological Theory,
3rd ed.
New York: Aldine De Gruyter, 1999.
“Mental Disorders in Cities.”American Journal of Sociology, v.48 (1942). http://dx.doi.org/10.1086/219077
Decarceration: Community Treatment and the Deviant. Englewood Cliffs, NJ: Prentice-Hall, 1977.
Decarceration: Community Treatment and the Deviant.
2nd ed.
Cambridge: Polity Press, 1984.
“The Decarceration of the Mentally Ill: A Critical View.”Politics and Society, v.6 (1976). http://dx.doi.org/10.1177/003232927600600202
“The Mental Health Sector and the Social Sciences in Post–World War II USA. Part I: Total War and its Aftermath.”History of Psychiatry, v.22 (2011).
“The Mental Health Sector and the Social Sciences in Post–World War II USA. Part II: The Impact of Federal Research Funding and the Drugs Revolution.”History of Psychiatry, v.22 (2011).
The Most Solitary of Afflictions: Madness and Society in Britain, 1700–1900. New Haven, CT: Yale University Press, 1993.
Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England. London: Allen Lane, 1979.
“Psychiatry and the Social Sciences, 1940–2009.”History of Political Economy, Suppl. v.42/5(2010).
and . The Mental Hospital: A Study of Institutional Participation in Mental Illness and Health. New York: Basic Books, 1954. http://dx.doi.org/10.1037/10670-000
and . “Community Mental Health Centers and Decreasing Use of State Mental Hospitals.”Community Mental Health Journal, v.12 (1976). http://dx.doi.org/10.1007/BF01419749
, , , and . “The Psychological Meaning of Mental Illness in the Family.”Journal of Social Issues, v.11/4 (1955).

## Chronology

1290: In England, the Act De Praerogative Regis gives the king custody of the lands and property of the mentally incapable; it also gives officers of the king, known as escheators, the right to hold inquisitions to determine the mental competency of individuals.

1377: In England, King Edward III establishes a “lunatic asylum” in the religious priory of St. Mary of Bethlehem; this institution gives rise to the term bedlam for an institution housing the mentally ill.

1520: The German physician Paracelsus (Phillipus Aureolus Theophratus Bombastus von Hohenheim) writes a book, Diseases Which Lead to a Loss of Reason, describing mental illness as caused by physical diseases rather than supernatural causes; it is published in 1657.

1621: The British scholar Robert Burton publishes The Anatomy of Melancoly, What It Is: With All the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of It, a collection of opinions from various authors on melancholia (depression). The first edition is almost 900 pages and includes poetry and historical accounts as well as excerpts from medical and scientific authorities.

1690: In An Essay Concerning Human Understanding, the English philosopher John Locke writes that everyone has some degree of madness in them.

1700: The British lawyer John Brydall publishes a commentary summarizing the legal status of persons deemed to be mentally incompetent, including drunks, “lunatics,” “idiots,” and “mad persons.”

1789: The American physician Benjamin Rush publishes an article defining “phobia” as “fear of an imaginary evil, or undue fear of a real one” and lists 18 specific examples of phobias.

1797: The French physician Jean Marc Gaspard Itard begins treating the “wild boy of Avalon,” who had apparently grown up in the woods without human care. Now considered an early case of autism, the “wild boy” died in 1828, and his story became known through Itard's writings and particularly through the 1970 film L'Enfant Sauvage, directed by François Truffaut.

1801: The French physician Philippe Pinel, director of the Salpetriere asylum in Paris, publishes A Treatise on Insanity. The book describes different types of insanity and outlines his ideas on what he called the “moral” treatment of the insane.

1812: The American physician Benjamin Rush publishes Inquiries and Observations on Diseasesof the Mind, the first psychiatric textbook published in the United States.

1829: Dorothea Dix, an American schoolteacher, begins her crusade to improve conditions for the mentally ill after observing insane people being held in inhumane conditions in a jail. One measure of her success is that she succeeded in getting 32 U.S. states to build hospitals specifically for mental patients.

1843: The Scottish craftsman Daniel M'Naghten, believing that his life is in danger, attempts to kill British prime minister Robert Peel but instead shoots and kills Peel's secretary, Edward Drummond. M'Naghten pleads not guilty by reason of “moral insanity;” the plea is successful and he is found not guilty of murder but is confined to an asylum. In response to this case, a panel of British judges develop what is known as the M'Naghten Rules, a series of questions to determine if a person is legally insane.

1844: The Association of Medical Superintendents of American Institutions for the Insane is founded in Philadelphia by superintendents from 13 of the 24 mental hospitals existing in the United States. The purposes of the association include professional study, communication, and assistance to improve the treatment of the insane.

1850: Patients at the Utica State Lunatic Asylum in New York State begin publishing a monthly newsletter, The Opal, including poems, essays, and reflections written by the patients. Proceeds from the sale of The Opal are used to buy books for the patients' library.

1852: The Swedish scientist Magnus Huss coins the term alcoholism, which he describes as an abusive level of alcohol consumption that he labels alkoholismus chronicus.

1865: In the United States, a trend toward large mental hospitals is established as the Willard State Hospital begins operation in New York. It has 1,000 beds, a contradiction to the recommendation of the Association of Medical Superintendents of American Institutions for the Insane that mental hospitals should contain no more than 250 beds. By the mid-20th century, some state hospitals contain as many as 10,000 beds.

1868: A report from Surgeon-Major R. F. Hutchinson details conditions in British “lunatic asylums” in Bengal, India. The asylums were founded after the British established their rule in 1858 and segregated patients by origin—Europeans were treated in modern private asylums, while Indians were housed in poorly maintained public institutions.

1872: The German neurologist Otto Westphal introduces the term agoraphobia in a paper describing three male patients who suffer from a dread or fear of public places. Westphal also remarks that the patients could be distressed simply by thinking of a feared situation without actually being in it.

1872: In British Columbia, Canada, the first insane asylum is established by the Royal Hospital in a cottage previously used for quarantined patients. It is closed in 1878 and the patients moved to a newly built asylum in New Westminster.

1873: The French physician Ernest Charles Lasègue identifies anorexia nervosa as a clinical diagnosis; he believes it is caused by the patient's desire to conceal emotional disturbances.

1874: The American physician George Miller Beard publishes Cases of Hysteria, Neurasthenia, Spinal Irritation, or Allied Affections, in which he describes a new disease, neurasthenia, which he believes is caused by an oversupply of nervous energy due to the demands of modern life.

1879: At the University of Leipzig, the German physician Wilhelm Wundt establishes the world's first experimental laboratory for psychological research; for this reason, Wundt is often cited as the father of experimental psychology.

1881: The Italian physician August Tamburini publishes “A Theory of Hallucinations,” a paper detailing different explanations offered for hallucinations (peripheral, intellectual, psychosensorial, and sensorial); it becomes one of the most cited papers in neuropsychiatry of its era.

1882: The German neurologist Richard von Krafft-Ebing publishes Psychopathia Sexualis. Written partly in Latin, this book describes many sexual disorders, including sadism and masochism, and was also one of the first books to discuss homosexuality and bisexuality.

1883: In his book, Inquiries Into Human Faculty and Its Development, British scientist Francis Galton coins the term eugenics for his advocation of improving the human race by encouraging or discouraging reproduction depending on the “merit” of the parents. His concepts continue to support eugenic ideas up to his death in 1912 and into the 1930s.

1883: The German psychiatrist Emil Kraepelin publishes Compendium der Psychiatrie, the basis for the modern system of classifying mental disorders. It calls for expanded study of mental disorders, including research into their physical causes, and case studies to clarify their typical progression.

1887: American reporter Nelly Bly publishes Ten Days in a Mad-House, an exposé based on her undercover reporting (posing as a patient) in the Women's Lunatic Asylum on Blackwell's Island (now Roosevelt Island) in New York City.

1893: The French physician Jacques Bertillon introduces the Bertillon Classification of Causes of Death, which is widely adopted in other countries. It forms the basis of the International Classification of Diseases system now used by the World Health Organization and many other organizations.

1895: The Austrian physician Sigmund Freud publishes Obsessions and Phobias: Their Psychical Mechanism and Their Aetiology. In the book, he distinguishes between phobias and obsessions by noting that while various emotions are involved in obsession, phobias are always accompanied by a state of anxiety.

1897: The French sociologist Émile Durkheim publishes Suicide, which includes an exploration of suicide rates among different demographic groups and a characterization of different types of suicides. Among his findings: suicide rates are higher in men than in women, among Protestants than among Catholics or Jews, and among single people than among those who are married.

1898: The Russian neurologist Sergei Korsakoff describes a syndrome seen in some long-term alcoholics as well as in some individuals with head injuries, brain tumors, or poisoning. Symptoms of Korsakoff's syndrome include disorientation, loss of memory, and confabulation (making up stories).

1899: The Austrian physician Sigmund Freud publishes The Interpretation of Dreams, introducing key concepts of psychoanalysis such as the Oedipus complex and the revelation of the unconscious through dreams.

1901–02: At the University of Edinburgh in England, American philosopher and physician William James delivers the Gifford Lectures in natural theology. An edited version of these lectures is published as The Variety of Religious Experience: A Study in Human Experience in 1902.

1903: The French psychologist Pierre Janet classifies neurotic disorders as either hysteria (disturbances in consciousness, sensation, and movement) or psychasthenia (including depression, obsessions, phobias, and anxiety).

1904: The Russian scientist Ivan Pavlov is awarded the Nobel Prize in Physiology or Medicine. In the course of his research on digestion at the Institute of Experimental Medicine, Pavlov discovered the principle of operant conditioning and of conditioned reflexes.

1906: The German psychiatrist Alois Alzheimer performs an autopsy on a patient who had suffered from short-term memory loss and other symptoms, and identifies within this patient's brain the characteristic neurofibrillary tangles and amyloid plaques now identified with Alzheimer's disease.

1908: The publication of A Mind That Found Itself, the autobiography of Clifford Beers, describes the poor conditions in mental asylums in the United States and leads to the founding of the advocacy group called the National Committee for Mental Hygiene.

1911: The Swiss psychiatrist Eugene Bleuler coins the term schizophrenia, derived from the Latin roots schizo (split) and phrenia (mind) to replace Emil Kraepelin's term for the same condition, dementia praecox.

1914–18: During World War I, over 600,000 German servicemen are treated in military hospitals for nervous disorders, including “male hysteria” (shell shock or post-traumatic stress disorder). The cause is believed to be shocks delivered to the nervous system. By 1918, 5 percent of hospital beds are reserved for patients with hysteria.

1916: The psychologist Lewis Terman, working at Stanford University, publishes a revised version of an intelligence test originally created in 1905 by the French psychologist Alfred Binet and the French physician Alfred Simon. The Stanford-Binet Intelligence Scales compare a child's performance with that expected of children of the same age, an approach still used in contemporary intelligence testing.

1917: The Austrian psychiatrist Julius Wagner-Hauregg begins investigating the benefits of induced fevers in mental patients and produces these fevers by inoculating the patients with blood infected with malaria. Wagner-Hauregg was awarded the Nobel Prize for Physiology or Medicine in 1927, and induced fever by malaria continued to be used to treat mental patients until approximately 1950.

1917: During World War I, the American psychologist Robert Woodworth develops the Personal Data Sheet to screen recruits for the U.S. Army. The Personal Data Sheet, a brief, self-reporting questionnaire about symptoms such as sleepwalking and suicidal thoughts, proves remarkably successful in separating mentally disturbed individuals from those functioning normally.

1919: The first forensic psychiatric facility in British Columbia, Canada, is opened on Vancouver Island. The Provincial Mental Home for the Criminally Insane opens with just nine patients but houses 99 by the end of the year.

1920: The American psychiatrist Edward Kemp coins the term homosexual panic to refer to the fear that one will be sexually assaulted by a member of one's own sex, or the fear that one may in fact be homosexual. Homosexual panic is sometimes cited as a cause for attacks on gay men, suggesting that the attacker is responding to an imagined threat caused by their discomfort with homosexuality.

1921: Fritz Lenz publishes the eugenics textbook Human Selection and Race Hygiene, synthesizing many contemporary ideas from medicine, anthropology, and genetics and arguing for the obligation to bar “undesirables,” including the mentally ill, from reproducing. It becomes a standard textbook in Germany, and Lenz later helps to draft the Nazi government's 1933 sterilization law.

1927: In the United States, Carrie Buck, a “feeble minded” woman involuntarily committed to the Virginia Colony for Epileptics and Feeble Minded, is sterilized in October; the state law that permits this type of sterilization for the purpose of eugenics is not repealed until 1974.

1929: The German psychiatrist Hermann Simon publishes “Active Therapy in the Lunatic Facility.” This article outlines the results of an experiment begun in 1905, when he observes that mental patients assigned some job to do become calmer and more orderly. Although the original purpose for having the patients work is to overcome a staff shortage, it proves so beneficial that when Simon becomes director of a different psychiatric facility, he has almost 90 percent of the patients doing some kind of work as part of their treatment.

1930: The American physician John Mayo Berkman publishes the first large-scale report on patients with anorexia. He discusses 117 patients treated over a period of 10 years and is often credited with bringing anorexia back into the consciousness of modern medicine.

1930: In the United States, the creation of the Mental Hygiene Division within the Public Health Service is originally concerned with operating two hospitals dedicated to treating addictions but also acts as a forerunner of the National Institute for Mental Health.

1932: The German neurologist Johannes Heinrich Schultz develops the technique of autogenic training to treat high blood pressure. Autogenic training is now used for stress relief and the treatment of sleep disorders and many other conditions. In autogenic training, the patient learns to achieve relaxation and induce a state similar to hypnosis.

1933: The Austrian psychiatrist Manfred Sakel begins administering insulin shock therapy to mental patients. In the procedure, the patient receives progressive doses of insulin until they go into a coma, then receives a sugar solution to restore consciousness. By 1941, almost three-quarters (71 percent) of American psychiatric facilities are using insulin shock therapy.

1933: About six months after Adolf Hitler is named chancellor of Germany and the Nazi Party forms a governing coalition, Germany passes the Law for the Prevention of Hereditarily Ill Offspring, providing for sterilization of those considered to have hereditary diseases, including the insane.

1935: William Griffith Wilson and Dr. Bob Smith found Alcoholics Anonymous (AA) in Akron, Ohio. AA is a self-help organization for alcoholics, with the goal of helping them achieve and maintain sobriety. Members of AA sometimes call themselves “friends of Bill W” after the AA tradition of not identifying members by their last names as a way to preserve their anonymity.

1938: The German psychiatrist Franz Kallman, working in the United States, is the first to suggest that there may be a genetic component to schizophrenia. He establishes the first full-time genetics department in a U.S. psychiatric hospital in part to research this hypothesis.

1938: In Canada, the Opium and Narcotics Act is amended to define codeine as a substance prohibited except when used by a physician to treat disorders other than addiction. Codeine was first regulated in Canada in 1923 but was deregulated in 1925.

1939: William Griffith Wilson and Dr. Bob Smith, founders of Alcoholics Anonymous, publish Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism. Known within AA as the Big Book, this volume was the first published statement of the Twelve-Step Method used in Alcoholics Anonymous to help alcoholics achieve and maintain sobriety.

1939: Robert E. Lee Faris and Warren H. Dunham publish Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses, an early example of a study linking socioeconomic status with mental health. In looking at residents of Chicago, Faris and Dunham find a strong relationship between the stressful conditions present in certain neighborhoods and mental illness in individuals.

1942: The psychologist Starke Rosecrans Hathaway and the psychiatrist John Charnley McKinley introduce the Minnesota Multiphasic Personality Inventory (MMPI), a commonly used method of assessing personality. The original MMPI requires individuals to agree or disagree with 550 statements and assesses them on nine personality scales: hypochondria, hypomania, depression, hysteria, schizophrenia, psychopathic deviate, masculine-feminine interest, paranoia, and psychasthenia.

1944: American child psychiatrist Leon Kanner creates the diagnosis of “early infantile autism,” or Kanner's syndrome, for children who are not interested in socializing but are not retarded or emotionally disturbed. At about the same time, the Austrian pediatrician Hans Asperger identifies a similar syndrome in a group of child patients. One distinction between Kanner's and Asperger's subjects is that all of Asperger's subjects are able to speak; hence, the term Asperger's syndrome is usually applied to autistic individuals with normal language development.

1946: In the United States, the National Institute of Mental Health is created as part of the National Mental Health Act. It is allocated $7.5 million to provide technical assistance to the states, train personnel, and conduct research. 1948: The American psychologist B. F. Skinner publishes Walden Two, a novel describing a fictional utopian community whose members adopt an experimental approach to all aspects of their life. Walden Two expresses Skinner's beliefs that free will does not exist and that human behavior is governed by a combination of genetics and environment. 1948: Journalist Albert Deutsch publishes Shame of the States, exposing the terrible conditions in state mental hospitals, which at the time are housing many mentally ill people. This report is influential in the deinstitutionalization movement in the United States. 1948: The American zoologist Alfred Kinsey publishes Sexual Behavior in the Human Male, the first of the so-called Kinsey Reports. This volume includes the Kinsey Scale, which ranks the sexuality of men from 0 (completely heterosexual) to 6 (completely homosexual), as well as the conclusion that 10 percent of men were primary homosexual for at least three years of their adult life. Kinsey's results have since been criticized on many grounds, including the selection of his sample, but are groundbreaking in terms of presenting objective data about the sexual practices of Americans. 1949: John Frederick Joseph Cade, an Australian psychiatrist, first uses lithium to treat psychosis. It becomes a standard treatment, replacing barbiturates and bromides, to treat manic depressive (bipolar) disease. 1949: The Portuguese neurologist Egas Moniz receives the Nobel Prize in Physiology or Medicine for his work in developing lobotomy (which he calls “leucotomy”) as a tool for treating psychotic patients. 1949: The American psychologist Carl Rogers publishes “The Attitude and Orientation of the Counselor in Client-Centered Therapy” in the Journal of Consulting Psychology, setting out his ideas on humanistic psychology, which was originally called “nondirective therapy.” 1950: The German American psychoanalyst and psychologist Erik Erikson publishes his book Childhood and Society, popularizing the term identity crisis and developing Freud's concept of infantile sexuality. 1951: The American sociologist Talcott Parsons publishes The Social System, which includes his concept of the “sick role” and the obligations and rights of a sick person. 1952: In France, the antipsychotic drug chlorpromazine (Thorazine) is first used to successfully treat psychosis. This and other antipsychotics provide breakthrough treatment for schizophrenia, with an estimated 70 percent of patients helped by antipsychotic drug therapy. 1952: The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) is published by the American Psychological Association. This classification of mental disorders becomes highly influential among mental health professionals. It has since been revised regularly, with the fifth edition published in 2013. 1952: The psychiatrist Fantz Fanon, born in Martinique and educated in France, publishes “The ‘North African Syndrome.’” This paper details Fanon's observations about how the experience of colonialism shaped the consciousness of North African migrant workers. 1953: August B. Hollingshead and Frederick C. Redlich publish “Social Stratification and Psychiatric Disorders” in the American Sociological Review, reporting that individuals in lower social classes, as compared to those in higher classes, are more likely to be treated for mental illness and more likely to suffer from more severe forms of mental illness. 1953: The American psychologist B. F. Skinner publishes Science and Human Behavior, which includes a description of his theory of operant conditioning. 1953: The American zoologist Alfred Kinsey publishes Sexual Behavior in the Human Female, the second of two “Kinsey Reports.” Although women in this study show a lower degree of homosexuality on Kinsey's 0–6 scale of sexual orientation, the report still arrives at the surprising conclusion that 1 to 3 percent of unmarried women aged 20 to 35 are rated 6 (exclusively homosexual). 1954: P. K. Benedict and I. Jacks publish “Mental Illness in Primitive Society” in the Journal for the Study of Interpersonal Processes, reporting that people in all societies experience all of the major psychoses identified in Western psychology and psychiatry, thus refuting the Freudian notion that neurosis is caused by conflict between repressive Western civilization and a person's instinctual drives. 1955: The Joint Commission on Mental Illness and Health, a task force created by the American Medical Association and American Psychiatric Association, is created to make recommendations to the U.S. Congress regarding creation of a national mental health program. 1955: The introduction of psychoactive drugs in the United States coincides with the beginning of a rapid decline in the number of mentally ill people held in mental hospitals. Some contend that it also helps speed the deinstitutionalization process by allowing some people with serious mental illness to function in assisted living facilities or with support from community mental health organizations. 1956: The Hungarian physician Hans Selye, working at McGill University in Canada, publishes The Stress of Life. In this book, Selye explains his theory of general adaptation syndrome, which describes how stress affects mental and physical well-being. 1956: The American Bar Association and the American Medical Association officially recognize alcoholism as a disease. This decision influences many areas of life, including insurance coverage for alcohol-related conditions and the legal status of alcoholics. 1957: The American psychologist Leon Festinger publishes his theory of cognitive dissonance, which describes how people behave when they experience a conflict among their beliefs, behaviors, and attitudes. Festinger argues that people are uncomfortable with cognitive dissonance and may change their attitudes to match their behavior. 1958: The South African physician Joseph Wolpe, working in the United States, publishes reports of his use of systematic desensitization to treat adults. The technique, which involves training a patient in relaxation techniques and then introducing a feared stimulus or having the person imagine a feared situation, works on the principle that a person cannot be anxious and relaxed at the same time. 1958: In his doctoral dissertation at the University of Chicago, the American psychologist Lawrence Kohlberg outlines his theory of the stages of moral development. Inspired by the work of Swiss developmental psychologist Jean Piaget, this theory suggests that as children mature, they are able to engage in more complex moral reasoning. Kohlberg's theory becomes extremely influential but is also criticized on the grounds that it emphasizes a male, Western point of view and values justice to the exclusion of other important values such as caring for others. 1959: The first methadone treatment program is established in British Columbia, Canada. Run by Dr. Robert Halliday, the program does not have the goal of abstinence but of maintenance; Halliday likens the program to insulin treatment for diabetics. 1959: E. Byrne studies patients in mental hospitals in Africa, Latin America, and the United States and concludes that the major mental illnesses such as schizophrenia manifest themselves in the same way in widely different cultures. 1960: The American physician and psychoanalyst Thomas Szasz publishes “The Myth of Mental Illness,” an essay outlining many of the ideas of the antipsychiatry movement, beginning with questioning whether such a thing as mental illness exists at all. 1961: Jum C. Nunnaly, Jr., publishes Popular Conceptions of Mental Health: Their Development and Change, arguing that public education is necessary to overcome the stigma of mental illness. Nunnaly's book is directed in part toward the deinstitutionalization taking place in the United States, in which care for mentally ill people is in the process of being shifted from large institutions that isolate the mentally ill from most of the population to community mental health treatment that aims to achieve as much integration of the mentally ill with “normal” communities as possible. 1962: The German American psychoanalyst Hilde Bruch publishes “Perceptual and Conceptual Disturbances in Anorexia Nervosa.” This paper differentiates between self-starvation caused by other psychiatric illness and primary anorexia, which is characterized by disturbed body image, a sense of helpless, and misinterpretation of stimuli such as hunger sensations. 1962: American author Ken Kesey publishes One Flew Over the Cuckoo's Nest, based on his experiences working in a Veterans Administration hospital. Kesey's best-selling novel is based on the antipsychiatry position that mental patients are simply nonconformists rather than people with genuine illnesses. 1963: In October, the U.S. Congress passes the Community Mental Health Centers Act, authorizing federal funds to create mental health centers in local communities to care for new mental health patients as well as individuals formerly housed in state mental hospitals. 1965: Michel Foucault's Madness and Civilization: A History of Insanity in the Age of Reason is published in English, translated from 1961 French editions. 1966: American sociologist Thomas J. Scheff publishes Being Mentally Ill: A Sociological Theory, articulating his theory that labeling deviant behavior as signs or results of mental illness stigmatizes individuals who display such behavior, with potentially profound effects such as the adoption of mental illness as part of the self-image. 1968: Four criteria—unresponsiveness to stimuli, no movement or spontaneous breathing, no reflexes, and no electrical activity in the brain—are proposed by a committee at Harvard Medical School to identify when “brain death” has occurred. The concept of brain death, which allows a physician to certify a patient as dead even if their heart and lungs may continue to function with the assistance of life-support equipment, remains controversial but has been adopted by some countries and some U.S. states. 1968: Thomas H. Holmes and Richard H. Rahe present a paper at the Royal Society of Medicine that includes their Life Change Rating Scale. This scale assigns a numerical value to different life events (for instance, 100 for the death of a spouse, 45 for retirement, 20 for change in residence or school) and instructs individuals to calculate their score by adding up the points for all the events that have happened to them in the past year. A higher score indicates greater stress and increased probability of illness in the upcoming year; for instance, a score between 150 and 300 predicts a 51 percent increase in the probability of illness. 1970: Gay rights activists disrupt the annual meeting of the American Psychiatric Association (APA), protesting the classification of homosexuality as a disease in the APA's Diagnostic and Statistical Manual of Mental Disorders. Partly as a result of this action, homosexuality is no longer listed as a disease in the 1974 printing of DSM-II. 1970: The American psychiatrist Aaron T. Beck publishes “Cognitive Therapy: Nature and Relation to Behavior Therapy,” a paper outlining his theory that elaborate explorations of a patient's past are not necessary to help depressive patients and that quicker results can be gained by simply challenging the truthfulness of their negative thoughts. 1975: The British secretary of state for social services issues a white paper, “Better Services for the Mentally Ill,” outlining the logic behind deinstitutionalizing the mentally ill, along with a brief history of how mentally ill people have been cared for in different historical periods. 1975: The American cardiologist Dr. Herbert Benson publishes The Relaxation Response, describing the physiological response some people experience as a result of transcendental meditation. Benson writes that this response can help people manage conditions such as high blood pressure, although he cautions that it is not a substitute for medical care and appropriate use of medication. 1975: Ken Kesey's novel, One Flew Over the Cuckoo's Nest, is made into a film directed by Milos Forman and starring Jack Nicholson. The film wins five Oscars, including Best Picture, and helps to popularize the antipsychiatry position that people in mental hospitals are nonconformists who are inconvenient to society, rather than people needing treatment for illnesses. 1976: The American journalist Norman Cousins publishes the essay “Anatomy of an Illness as Perceived by the Patient,” describing his experience with the disease ankylosing spondylitis, a form of arthritis. He claims that he was able to improve his condition by ending medical treatment, taking large doses of vitamin C, and watching humorous movies in a comfortable hotel room rather than the hospital. His case history is groundbreaking in its approach to the patient taking charge of their own health, sparking the trend of patients working with their doctors and using humor for healing. 1977: At its annual meeting, the World Psychiatric Association (WPA) issues a proclamation condemning the use of psychiatric institutionalization of political dissidents in the Soviet Union. The WPA also issues a code of ethics called the Declaration of Hawaii, which specifies, among other things, that patients must be informed of treatment options and must consent to treatment unless they lack the capacity to reason. 1977: Edna Rawlings and Dianne Carter publish Psychotherapy for Women, a book claiming that social and external causes, rather than internal and personal forces, are behind many women's psychological problems and that society should become more just rather than expecting women to cheerfully adapt to the unjust state of society. 1979: The National Alliance for the Mentally Ill, a grassroots advocacy and support organization for people with mental illness, is founded in the United States. 1980: For the first time, post-traumatic stress disorder (PTSD) appears in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. 1980–85: The first Epidemiologic Catchment Area Survey of Mental Disorders is conducted in the United States. It is the largest and most comprehensive survey of its type, conducted to determine the overall prevalence of mental disorders—not just among those who sought treatment—and the need for mental health services. 1983: The American singer Karen Carpenter dies of cardiomyopathy at age 32 after years of suffering from anorexia and bulimia and abusing syrup of ipecac to induce vomiting. Her death brings great publicity to the risks of anorexia and bulimia, particularly for young women. 1986: The passage of the Consolidated Omnibus Budget Reconciliation Act (COBRA) increases the ability of U.S. employees to retain employer-sponsored health insurance for a period after they leave a job. 1988: Marti Loring and Brian Powell publish an article in the Journal of Health and Social Behavior that casts doubt on the objectivity of the psychiatric diagnosis process. After sending the description of symptoms to different psychiatrists, along with varying gender and racial characteristics, they find that the diagnoses vary by the gender and race of the hypothetical patient as well as the gender and race of the psychiatrist making the diagnosis. 1989: In Japan, a study of employees of Chiyoda Fire and Marine Insurance, Ltd., popularizes the term karoshi, meaning death from overwork, and focuses attention on sources of stress for Japanese workers. These findings are later applied to workers in other countries, with the general conclusion that workers who experience high levels of stress from high work demands, coupled with low levels of control and low social support, are at increased risk for many diseases and behaviors such as drug and alcohol abuse. 1989: Dennis E. Clayson and Michael L. Klassen release the results of a study demonstrating that many Caucasian American college students hold negative views of obese people, associating them with characteristics such as lazy, unhealthy, insecure, and lacking in self-discipline. 1989: the U.S. Department of Veteran's Affairs creates the National Center for Posttraumatic Stress Disorder to treat military veterans with post-traumatic stress disorder (PTSD) and to advance research and clinical practice for individuals suffering from this condition. 1989: John Mirowsky and Catherine E. Ross publish an article in the Journal of Health and Social Behavior estimating that social conditions are a primary influence in depression. According to their research, half of depressive symptoms could be explained by social conditions, and an even higher proportion (almost three-quarters) of those symptoms could be explained by positions of low personal control and social position. 1990: The passage of the Americans with Disabilities Act prohibits discrimination against the disabled in employment. The definition of “disabled” includes those with mental illness and requires employers to make “reasonable accommodations” if necessary to allow a person with a disability to perform a job. 1990: In the United States, the Consortium on Child and Adolescent Research (C-CAR) is established within the National Institute of Mental Health. C-CAR works to facilitate research and the exchange of knowledge on children and young people with developmental, emotional, and brain disorders. 1991: The Epidemiologic Catchment Study (ECA), a community mental health survey conducted between 1980 and 1983, is published in the United States. Based on interviews with almost 20,000 adults, the ECA is able to provide estimates of the incidence and prevalence of mental disorders, whether or not sufferers have sought treatment. 1993: The American psychologist Jon Kabat-Zinn publishes Mindfulness Meditation in Everyday Life. The book helps to popularize mindfulness meditation, a type of meditation drawing on Buddhist traditions, to reduce stress and induce relaxation, with claims that it also helps treat physical disorders. 1994: The Alzheimer's diagnosis of former U.S. president Ronald Reagan is made public. This announcement brings heightened awareness of the disease as well as speculation about how long Reagan might have been suffering from it. 1994: Results from the National Comorbidity Study, the first study in the United States to estimate the prevalence of psychiatric disorders using a national probability sample, is published. One of the striking findings is the strong relationship between socioeconomic status (SES) and psychiatric disorders. Lower SES is associated with higher probability of psychiatric disorder. 1996: A study from the Chinese University of Hong Kong reports that eating disorders and body dissatisfaction have become common among Chinese adolescent girls, suggesting that this is due to the increasing influence of Western cultures. 1996: In the United States, the Mental Health Parity Act (MHPA) becomes law. The MHPA requires that group insurance plans covering more than 50 workers provide annual and lifetime medical benefits limits for mental health at least as high as those provided for medical and surgical benefits. 1997: Jo Phelan and Ann Steuve present a paper at the American Sociological Association in Toronto, showing that U.S. public opinion toward the mentally ill has become more negative over the past 50 years. This is a surprising result because it is generally believed that deinstitutionalization and community mental health treatment would have reduced the stigma associated with mental illness. 1998: In Canada, constable Gil Puder, speaking at the Fraser Institute Forum, calls for an end to the Canadian War on Drugs and the creation of a harm reduction program in its place. 2001: A study published by Joshua Rubinstein, Jeffrey Evans, and David Meyer in the Journalof Experimental Psychology declares that “multitasking” does not exist and what looks like multitasking is in fact switching attention rapidly from one task to another. They also report that, contrary to popular belief, rapid switching between tasks may not be efficient because people lose significant amounts of time as they switch from one task to another and that this loss of time increases with the complexity of the tasks performed. 2001: The World Health Organization dedicates World Health Day (April 7) to mental health, and the “World Health Report 2001” is also dedicated to mental health. According to the report, about 450 million people around the world suffer from a mental disorder and 25 percent will be affected by a mental disorder at some point in his or her life. 2005: In Vancouver, British Columbia, the North American Opiate Medication Initiative clinical trials test whether people who are suffering from chronic opiate addictions (and have not been helped by other treatments) might be aided by heroin-assisted therapy. 2008: A report by the American Psychoanalytic Association finds that while psychoanalysis is frequently discussed in U.S. college classes in the humanities, including history, literature, and film, it is not customarily taught in university classes in psychology departments. 2008: A bill decriminalizing adult use of marijuana is introduced in the U.S. Congress but does not pass. It is reintroduced in 2009 but, again, it does not pass. 2010: The U.S. Centers for Disease Control and Prevention (CDC) report that the diagnosis of attention deficit hyperactivity disorder (ADHD) in the United States increased by an average of 3 percent per year from 1997 to 2006. The CDC also reports that several studies found a link between blood lead levels and symptoms of hyperactivity and impulsivity. 2010: Clayton R. Cook of the College of Education at the University of Washington and colleagues from the University of California, Riverside publish a literature review in School Psychology Quarterly showing that poor academic performance and poor problem-solving skills are highly predictive of which children would engage in bullying behavior. 2010: Psychologist Scott Huetell and colleagues publish a report in Psychology and Aging showing that, after controlling for cognitive abilities such as memory, the tendency to make risky decisions does not increase with age, contrary to popular belief. 2011: The New York Times reports that many U.S. psychiatrists no longer provide talk therapy to their patients because of difficulties getting health insurance companies to pay for the treatment, and rely increasingly on drug therapies instead. 2011: A study by Aaron T. Beck and colleagues, published in the Archives of General Psychiatry, finds that patients with severe schizophrenia respond well to a type of cognitive behavior therapy originally developed to treat depression. 2012: A report from the Substance Abuse and Mental Health Services Administration states that about 20 percent of Americans experienced mental illness in 2010 and about 5 percent had mental illness sufficiently severe to interfere with daily life. 2012: The American Psychiatric Association announces that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has been completed and will be published in 2013. Among the changes in the new edition: classification of hoarding, binge eating, and severe premenstrual syndrome as disorders; stricter definitions of autism spectrum disorder; and lumping the term Asperger's syndrome under autism spectrum disorder rather than listing it as a separate diagnosis. 2012: In the United Kingdom, mental health patients are granted the right to choose the consultant psychiatrist who treats them, increasing parity between mental and physical illness treatments. The change will go into effect in 2014. 2012: American psychologist Lena Brundin, from Michigan State University, and an international team of colleagues publish an article in Neuropsychopharmacology offering proof that the chemical glutamate is linked to suicidal behavior. This means that glutamate levels should be monitored in those deemed potentially suicidal and that antiglutamate drugs may help prevent suicide. 2012: A report by the World Health Organization calls conversion therapy, which claims to be able to “cure” gay men and lesbians and make them heterosexual, a threat to the lives and well-being of those subjected to it. 2013: In California, the Investment in Mental Health Awareness Act of 2013 creates a grant program to help counties, public agencies, and nonprofit agencies develop mental health crisis support systems. 2013: May 2013 sees the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, DSM-5. A week before it appears, Thomas Insel, director of National Institute of Mental Health (NIMH), objected to “its lack of validity” and reliance upon the outmoded idea of defining and diagnosing illnesses o the basis of symptoms. “Mental patients deserve better,” he proclaimed, and he indicated that NIMH would “be reorienting its research away from DSM categories.” 2013: In September, Statistics Canada releases results from a national population health survey which found that 17 percent of Canadians aged 15 or older felt they had an unmet need for mental health care in the previous 12 months. 2013: On October 10, National Football League player Brandon Marshall wears green cleats during a game between the Chicago Bears and the New York Giants. This occurs during Mental Health Awareness Week to raise awareness about mental health. 2013: In November, the National Alliance on Mental Illness announces a new national program, “Ending the Silence,” which educates high school students about mental illness. 2013: In November, Kathleen Sebelius, Secretary of Health and Human Services, announces new regulations that require health insurers to cover mental health care on the same basis that they cover physical health care. Although theoretically, mental health care parity has been required by law since 2008, the new regulations make it more difficult for insurers to evade the law. • ## Glossary • Access to care: The ability of someone who needs medical, psychiatric, or psychological treatment to receive that treatment. Access includes both the ability to get to treatment (a particular problem for people living in rural areas) and the ability to pay for the services or have someone else, such as an insurance company, pay for them. Access to care for mental health services has been a much-contested issue in the United States, as some insurance plans provide less coverage for mental health services than for medical services. • Acculturation: The process of becoming familiar with a new culture or environment and becoming able to function effectively in it. Acculturation is often discussed in relation to people emigrating from one country to another or to people in a minority culture within a country (for instance, Mexican Americans in the United States). • ACT: Assertive community treatment, an integrated approach to community mental health care, including treatment, rehabilitation, and continuing support. ACT is typically provided by a multidisciplinary team of professionals and is particularly recommended for individuals with persistent, severe mental illness. • Acute somatoform illnesses: The technical name for what are sometimes called “hysterical illnesses” or “mass psychogenic illnesses,” in which individuals complain of physical symptoms and/or display behaviors associated with physical illnesses but without an identifiable physical cause. • Addiction: Physical or psychological dependence on a chemical substance (such as alcohol, tobacco, heroin) or activity (such as gambling, sex) so that the person feels a compulsion or craving to repeat the activity or access the substance and may suffer withdrawal symptoms if it is not available. • ADHD: Attention deficit/hyperactivity disorder, a disorder characterized by impulsivity, inattention, and hyperactivity. ADHD is one of the more commonly diagnosed disorders in school-age children, perhaps because it impairs their ability to function in a typical classroom. Diagnosis of ADHD has greatly increased in some countries (including the United States) in recent years, and the disease itself, as well as methods to treat it, is a frequent source of controversy. • Adjustment disorders: Emotional and/or behavioral symptoms that are triggered by an identifiable stressor (such as the end of a marriage), are clinically significant, and arise within three months after the stressor occurs. The American Psychological Association's definition of adjustment disorders includes several different ways an adjustment disorder may be identified, including anxiety, depressed mood, and disturbed emotions or conduct. • Adult day care centers: A service offered in some countries, often through nonprofit agencies or nursing homes, that allows dementia patients to eat and participate in daily activities at a care center, then return home to sleep. • Affective disorders: See Mood disorders. • Ageism: Discrimination by someone on the basis of age; the term is most commonly applied to discrimination against older people. Although age discrimination in employment is against the law in the United States and some other countries, many believe it still takes place because it is difficult to prove age discrimination in a court of law. • Agoraphobia: The fear of being in open, public places. Agoraphobia is often linked with panic disorder, in which a person may experience attacks of overwhelming anxiety. The inability to control these attacks may contribute to an agoraphobic's fear of being in a public place. • Alcoholism: A condition characterized by alcohol consumption at a level such that it causes problems for the individual. The designation of alcoholism as a mental disorder or disease is controversial because some consider alcohol consumption a voluntary behavior, and the definition of when the consumption of alcohol becomes a problem depends in part on social and cultural factors. • Amok: A culturally specific behavior observed in some Asian and south Pacific countries, including Polynesia, Papua New Guinea, the Philippines, Malaysia, and Laos. Episodes of amok are characterized by aggressive behavior and dissociation, and these episodes are more common in men than women. • Anhedonia: The inability to feel enjoyment or the diminished ability to feel enjoyment. Anhedonia has been identified in people suffering from several types of mental illness, including depression, schizophrenia, and neurosis. • Anorexia nervosa: An eating disorder characterized by disordered body image (the belief that one is fat when one is in fact quite thin) and severely restricted food consumption. • Antabuse: The proprietary name for disulfiram, a drug used to treat alcoholics by creating an aversion to alcohol. Because Antabuse interferes with the body's ability to metabolize alcohol, when a person taking Antabuse consumes alcohol, they suffer unpleasant symptoms such as vomiting, headache, and breathing difficulties. • Antipsychiatry movement: A movement led by American psychiatrist Thomas Szasz that posited that mental illness was a “myth,” that is, not descriptions of real illnesses but rather labels applied to deviant, disapproved behaviors. • Antisocial personality disorder: A disorder characterized by a refusal or inability to acknowledge the rights and feelings of others and behave in a socially acceptable manner. While some people with antisocial personality disorder engage in criminal behavior, certain characteristics of the disorder may also promote success in business, finance, or other fields. • Anxiety disorders: Disorders characterized by an unusual degree of tension or apprehensiveness in response to a perceived danger. Anxiety disorders are one of the more common mental illnesses; according to the American Psychiatric Association, approximately 20 million Americans are affected by anxiety disorders. These disorders include phobias, post-traumatic stress disorder (PTSD), and panic disorder. • Asperger's syndrome: An autism spectrum disorder characterized by difficulties in social interaction and intense interest in a small set of activities. Individuals with Asperger's syndrome do not usually have language or cognitive delays, and some argue that with appropriate educational and social support, they have particular aptitude for some professions (such as engineering and computer programming). • Barbiturates: Drugs that depress the central nervous system and may be used to treat anxiety and insomnia. Today, barbiturates are used less to treat these conditions because they are toxic and addictive and can worsen insomnia if used over a period of time. • Blood-brain barrier: A physiological barrier that prevents chemicals formed of large molecules from passing from the bloodstream into the brain. This mechanism protects the brain from substances that might harm it but also poses a barrier to diagnosis, as it makes it difficult to create blood tests to identify many specific mental disorders. • Body image: Beliefs a person holds about his or her appearance and body, which may or may not correspond to reality. For instance, people with eating disorders may believe themselves to be fat while in reality they are abnormally thin. • Brain imaging: Computer techniques to visualize images of the brain without performing surgery. Examples of brain imaging techniques include magnetic resonance imaging (MRI), computerized axial tomography (CAT), and positron emission tomography (PET). • Brainwashing: A set of psychological techniques used to control or indoctrinate individuals so that they seem to have no ability to think for themselves. Brainwashing first came to worldwide attention during the Korean War but has also been cited in the methods used by religious or other cults to indoctrinate their followers. • Bulimia nervosa: An eating disorder characterized by a distorted body image and a pattern of bingeing (eating large quantities of food in a short amount of time) followed by purging (vomiting or using laxatives) so that the food does not remain in the body long enough to cause weight gain. • Case management: Coordination of care and services for mental and/or physical care. A case manager is often placed in charge of coordinating services for an individual, which are provided by a number of specialists such as physicians, counselors, and social workers. • CIT: Crisis Intervention Team, an approach developed in Memphis, Tennessee, in which a team of law enforcement officers trained in de-escalation techniques respond to mental disturbance calls such as suicide attempts. CIT has been successfully replicated in other U.S. cities, including Durham, North Carolina; Albuquerque, New Mexico; Seattle, Washington; and San Jose, California. • Club drugs: A number of drugs whose use is associated with young people, night clubs, and dance parties, although they may also have legitimate medical uses. Examples of club drugs include MDMA (Ecstasy), ketamine, GHB, and flunitrazepan (Rohypnol). • Community mental health: The practice of providing mental health services within a community setting, with patients living independently or in supported circumstances (such as halfway houses) and receiving treatment on an outpatient basis rather than being confined to a mental hospital. • Co-occurring disorders: Also known as dual diagnosis disorders or comorbidities, two or more disorders occurring simultaneously in a patient. The term is most often applied to the co-occurrence of mental health and substance abuse disorders but can apply to any co-occurring disorders. • Conduct disorder: A personality disorder characterized by behaviors such as truancy, vandalism, and substance abuse, most commonly diagnosed in children and adolescents. • Decompensation: In psychology, the return to a lower level of functioning and adaptation, often when an individual is placed under severe stress. • Deinstitutionalization: The process of moving mental patients out of large state mental hospitals, presumably into less restrictive care provided in a community setting, and the consequent closing of many state mental hospitals. • Depression: A mood disorder characterized by feelings such as sadness, hopelessness, lethargy, and helplessness. Although depression can occur with anyone and at any age, it is more common in women than in men and is also associated with particular age groups (for men, major depressive episodes peak between the ages of 50 and 75, while for women, they peak between the ages of 20 to 45). • Deviant behavior: Behavior that violates role expectations and other norms of a particular society, in particular if such behaviors are disapproved of by the society. Deviant behavior can include anything from criminal behavior (such as committing murder) to violations of cultural expectations (such as refusing to get married to a member of the opposite sex). • Dissociative disorders: Disorders characterized by the disruption of identity, consciousness, memory, and perception. There are several types of dissociative disorders, including dissociative fugue, in which a person suddenly leaves familiar surroundings and is confused about their identity or takes on a new identity; depersonalization disorder, in which a person feels detached from their body or mental processes; and dissociative amnesia, in which a person is unable to recall personal information. • Diversion program: A law enforcement program that allows some individuals to avoid criminal justice penalties if they agree to treatment. Diversion programs are often used in the United States to offer options to minor drug offenders and the mentally ill. • Down syndrome: A type of mental retardation in which an individual is born with an extra copy of the 21st chromosome (Trisomy 21). People with Down syndrome have a distinctive physical appearance and often suffer from physical difficulties such as heart defects, cataracts, and digestive problems. Prenatal screening tests can indicate the probability of a baby being born with Down syndrome, and diagnostic tests such as amniocentesis can be used to follow up if the screening test indicates a high probability of Down syndrome. • DTs: Delirium tremens, symptoms often seen in severe alcoholics or after withdrawal from alcohol. Symptoms of the DTs include rapid pulse, excessive perspiration, high temperature, delusions, and hallucinations. • ECT: Electroconvulsive therapy, a treatment for depression involving passing a low-voltage current through a person's brain while they are sedated. ECT is also known as electroshock therapy and was introduced into psychiatric treatment in 1938. • EMDR: Eye-movement desensitization and reprocessing, a therapeutic technique developed in the 1990s to treat post-traumatic stress disorder, eating disorders, and other conditions. EMDR involves the patient moving their eyes in response to movement of a light manipulated by the therapist and may also involve tapping on the hands or face. • Epidemiologic Catchment Area (ECA) Survey of Mental Disorders: A series of surveys initiated in the United States in 1977 as part of a program to collect research data on the prevalence of mental disorders and the need for mental health services. The first ECA survey was conducted from 1980 to 1985 and at the time was the largest survey relating to mental health conducted in the country. • Epidemiology: The study of disease occurrence in populations (descriptive epidemiology), the correlates of the occurrence of disease (analytic epidemiology), and the results of interventions intended to change population health (experimental epidemiology). • Family therapy: Psychotherapy focused on the family as a unit rather than on members of the family as individuals. Family therapy is particularly popular when dealing with the psychological issues of children and adolescents because the family provides much of the context for their lives. • First-generation antipsychotic: Also known as typical antipsychotics or traditional antipsychotics, a number of drugs developed in the 1950s to treat schizophrenia and other psychotic disorders; examples include haloperidol and chlorpromazine. Because first-generation antipsychotics often produce serious side effects, they have largely been replaced by less dangerous drugs. • Gender identity disorder: A disorder in which an individual's anatomical gender is inconsistent with their psychological gender identification. According to the American Psychiatric Association, a diagnosis of gender identity disorder must include strong and persistent cross-gender identification, persistent discomfort with one's anatomical gender, and impairment in social or other important areas of functioning. • Iatrogenic disorder: A disorder caused by medical care or treatment. In psychiatry, the term often refers to psychiatric symptoms caused by an unexpected reaction to medication prescribed for another purpose. • Inhalant abuse: The use of inhalable chemical vapors, such as solvents or aerosols, to produce intoxication. The intoxication effect occurs because the inhalants starve the brain of oxygen and may produce hallucinations, slurred speech, dizziness, and other symptoms. • Labeling theory: A theory explaining mental illness as a product of labeling. As some deviant behavior is identified and labeled by others as an indication of mental illness, the deviant individual accepts the label as part of their identity and tends to act in accordance with the label. • Learned helplessness: A term coined by Martin Seligman to describe a response adopted by some individuals who feel they have no control over a situation. These individuals, who typically have been hindered in their ability to initiate behavior, often lose motivation, become passive, and may become depressed. • Lithium: An element used since the 1940s to treat manic and manic-depressive patients. Adoption of lithium as a treatment was slowed by the fact that it is a toxic substance and could produce side effects, including death. However, the availability of methods to monitor the blood levels of lithium in patients, particularly since the 1970s, has facilitated its increased use to treat bipolar disorder. • Medical model: A model for mental disorders based on the assumption that they have a chemical, genetic, or physiological basis like any physical disease and can be treated in a similar manner to physical diseases. • MMPI: The Minnesota Multiphasic Personality Inventory, a commonly used self-rating assessment of personality. Originally developed in 1942, the MMPI is used in psychiatric settings but also for other purposes, including screening individuals for high-risk employment and in counseling. • MMSE: The Mini-Mental State Examination, a brief method of evaluating a person's cognitive functioning. The MMSE is often used with elderly patients to assess their orientation, recall, language, and ability to follow commands based on simple questions such as, “What is the day of the week?” and tasks such as counting backward by fives. • Mood disorders: Disorders characterized by a change in mood sufficient to require clinical attention. Mood disorders are differentiated by thought disorders such as schizophrenia because mood disorders do not typically involve disordered thought processes but instead are characterized by extremes of sadness or elation. Examples of mood disorders include bipolar disease (manic-depressive disease), major depression, cyclothymia, and dysthymia. • Munchausen syndrome: A disorder in which a person complains of physical symptoms that do not in fact exist or that are self-inflicted. Also known as factitious disorder, Munchausen syndrome is generally attributed to a need for attention and may result in a person receiving medical tests and even treatments that they do not need. • Munchausen syndrome by proxy: Presenting a child for medical treatment and describing symptoms that have been induced by the caretaker or do not exist. The motivation of Munchausen syndrome by proxy (MSbP) is believed to be the desire of the adult to assume the sick role by proxy. MSbP is considered child abuse because it can harm the child, either through the induced symptoms or by causing the child to undergo unnecessary medical procedures. • Neurodiverse: A term applied to people who are neurologically different from so-called neurotypicals or normal. Examples of conditions that might qualify someone as neurodiverse (the term is contested) include Asperger's syndrome, attention deficit hyperactivity disorder (ADHD), and dyslexia. • OCD: Obsessive-compulsive disorder, an anxiety disorder characterized by repeated, intrusive thoughts and compulsive, ritualized behavior such as repeatedly washing one's hands. OCD may make it impossible for an individual to live a normal life because so much time and energy must be devoted to their rituals. • Opioids: Substances derived from the opium poppy, or synthetic derivatives or completely synthesized substances that deliver similar effects. Natural opioids include morphine and codeine, synthetic derivatives include heroin and oxycodone, and completely synthetic opioids include meperidine (Demerone), methadone, and dextropropoxyphene hydrochloride (Darvon). • Phobia: A type of anxiety disorder characterized by an intense, persistent, and unrealistic fear of something. Many types of phobias have been identified, from phobias triggered by specific objects (such as dogs and spiders) or situations (such as flying) to more generalized phobias such as social phobia and agoraphobia. A person with a phobia may try to avoid the object or situation that triggers it and may suffer a panic attack or other anxiety responses if exposed to it. • Pibloktoq: A culture-related syndrome seen primarily in arctic and subarctic Inuit communities. Pibloktoq is characterized by an abrupt and brief dissociative episode followed by convulsions or a coma. During the dissociative episode, the individual may tear their clothing, destroy property, or perform other violent acts but will have no memory of these behaviors after the attack. • Postpartum depression: Depression in a woman following the birth of her child. Many factors are thought to contribute to postpartum depression, including hormonal changes following pregnancy, sleep deprivation caused by the need to attend to the baby, fear of the responsibilities of motherhood, and confusion from the changes in routine and loss of status based on employment. • Psychoanalysis: A method of treating mental illness developed by Sigmund Freud and practiced by individuals who have undergone specialized training. Psychoanalysis is a talk-based therapy intended to increase self-understanding, and psychoanalysts use techniques such as free association and dream analysis in their work. • PTSD: Post-traumatic stress disorder, an anxiety disorder caused by a stressful event such as military combat or physical assault. PTSD may also be caused by witnessing a stressful event such as a crime. Symptoms of PTSD, which may occur long after the precipitating event, include re-experiencing the trauma, insomnia, emotional numbness, and avoidance of activities associated with the trauma. • Refrigerator mother: A term popularized in the 1950s by Bruno Bettelheim to characterize mothers of autistic children. The implication was that the mothers acted in a “frigid” manner toward their children and thus were responsible for the children's disorders; this term has been largely discarded. • Respite care: Short-term care provided to someone with a serious mental disorder or an elderly person in order to allow the usual caretakers (often relatives of the person requiring care) to take a break from providing the care. Respite care is considered an important factor in relieving the stress of taking care of a difficult or demanding individual and preventing burnout of caretakers. • Ritalin: Methylphenidate hydrochloride, a stimulant used to treat some children with attention deficit hyperactivity disorder (ADHD) and increase their ability to perform well in school. The use of Ritalin and other stimulants for this purpose is controversial and has been banned in some countries. • Role occupancy theory of depression: A theory suggested by Walter Gove and others, beginning in the 1970s, explaining the fact that women suffer more from depression than men as a product of the relatively small number of roles available to adult women in Western society and the resulting stress caused by the lack of fit to one's role. • SAD: Seasonal affective disorder, a mood disorder believed to be triggered by less exposure to sunlight during certain seasons of the year, such as winter in the Northern Hemisphere. It may be relieved by using a lamp that creates bright light similar to the sun's rays. • Sandwich generation: A term used to describe adults who find themselves caring for children or grandchildren while at the same time caring for aging parents. The term was popularized in the 2000s, as it was noted that many who found themselves in this situation suffered many anxieties and role confusions due to the conflicting demands placed on them. • Schizophrenia: A group of chronic mental disorders characterized by distortions of thought, perception, and speech. Schizophrenia can manifest itself in many ways, including fears of persecution (paranoid schizophrenia), hallucinations, disturbances in affect, and withdrawal from reality. • Second-generation antipsychotics: Also known as atypical antipsychotics, this group includes drugs such as dibenzoxazepine (Clozapine), benzisoxazole (Risperidone), and thienbenzodiazepine (Olanzapine) that are more effective and have fewer side effects than first-generation antipsychotic drugs. • Selection/drift hypothesis: A hypothesis explaining the relationship between socioeconomic status and mental illness by suggesting that mental illness causes people to occupy lower rungs on the socioeconomic ladder, as they are less able to compete for good jobs or finish their education because of their illness. • Self-efficacy: A term popularized in the 1970s by the Canadian American psychologist Albert Bandura, referring to beliefs or expectations an individual may hold about their ability to perform some task or behavior. Bandura believed that one goal of counseling should be to increase an individual's self-efficacy in targeted areas through vicarious learning and experience with the behavior. • Self-injury: Deliberately causing harm to oneself, but without the intention to commit suicide, by means such as cutting or burning one's skin, pulling one's hair out, or ingesting toxic substances. • SES: Socioeconomic status, a method of identifying a person's social position on the basis of factors such as income, type of occupation, and educational level. Many studies have found relationships between SES and mental health, with the typical finding that persons in lower SES categories are more likely to suffer from mental illness. • Sick role: A concept developed by the American sociologist Talcott Parsons, which defines the obligations (trying to get well, seeking competent medical help, and following medical advice) and the rights (exemption from blame for sickness, exemption from normal social roles) of a sick person. • Social causation hypothesis: A hypothesis explaining the relationship between socioeconomic status (SES) and mental illness as being due to the greater stress, vulnerability to threats, and lack of resources common among people in lower SES categories as compared to those in higher SES categories. • SSRI: Selective serotonin reuptake inhibitors, a class of drugs used since the 1980s to treat depression. Examples of SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), and paroxetine (Paxil). • Substance abuse: Use of a drug, alcohol, or other substance to the point that it causes difficulties for a person. Substance abuse is at least partially culturally defined because the same substance may be outlawed, and thus problematic for that reason alone, in one country and yet may be used freely in another country. In addition, different cultures place different values on states such as intoxication, and what is accepted in one culture may be considered problematic in another. • Systematic desensitization: A method used to treat phobias by training an individual in relaxation techniques and then gradually introducing stimuli related to the phobia, or having the person imagine the situation that triggers the phobia. • Tardive dyskinesia: A disorder characterized by delayed onset of involuntary and repetitive body movements. Tardive dyskinesia is a known side effect of first-generation antipsychotic drugs. • Valium: The brand name for diazepam, a benzodiazepine drug that is used to treat conditions such as anxiety disorders, muscle spasms, and withdrawal from alcohol. • World Health Organization Mental Health Gap Action Program (mhGAP): A program by the • World Health Organization intended to increase services for people suffering from mental, neurological, and substance use disorders, with particular emphasis on low- and middle-income countries. • World Mental Health Day: A day each year (October 10) designated by the World Health Organization to raise global awareness of mental health issues. ## Resource Guide Books , , and . Personality Disorders and Culture: Clinical and Conceptual Interactions. New York: Wiley, 1998. and , eds. Exile Cultures: Misplaced Identities. New York: Rodopi, 2008. and . Handbook of the Sociology of Mental Health. New York: Kluwer Academic/Plenum Publishers, 1999. , ed. Adolescent Psychiatry Around the World. New York: Psychology Press, 2012. Teenagers: A Natural History. Berkeley, CA: Greystone, 2009. Exotic Deviance: Medicalizing Cultural Idioms—From Strangeness to Illness. Boulder: University Press of Colorado, 2000. and . Broadening the Dementia Debate: Towards Social Citizenship. Portland, OR: Policy, 2010. , , and , eds. Handbook of Health Psychology. New York: Psychology Press, 2012. Benson, Jilly and Jill Thistlethwaite. Mental Health Across Cultures: A Practical Guide for Health Professionals. New York: Radcliffe, 2009. . Culture and Self-Harm: Attempted Suicide in South Asians in London. New York: Psychology Press, 2004. and , eds. Medicine, Madness and Social History: Essays in Honour of Roy Porter. New York: Palgrave Macmillan, 2007. http://dx.doi.org/10.1057/9780230235359 The Age of Melancholy: “Major Depression” and its Social Origins. New York: Routledge, 2005. What Is Mental Disorder? An Essay in Philosophy, Science, and Values. New York: Oxford University Press, 2008. http://dx.doi.org/10.1093/med/9780198565925.001.0001 and . Mind, Meaning, and Mental Disorder: The Nature of Causal Explanation in Psychology and Psychiatry. 2nd ed. New York: Oxford University Press, 2003. Appreciating Asperger Syndrome: Looking at the Upside, With 300 Positive Points. Philadelphia: Jessica Kingsley, 2009. Brain-Disabling Treatment in Psychiatry: Drugs, Electroshock, and the Psychopharmaceutical Complex. 2nd ed. New York: Springer, 2008. and , eds. Identity and Affect: Experiences of Identity in a Globalising World. Sterling, VA: Pluto Press, 1999. and . Helping the Helpers Not to Harm: Iatrogenic Damageand Community Mental Health. New York: Brunner-Routledge, 2001. The Parent Effect: How Parenting Style Affects Adolescent Behavior and Personality Development. Washington, DC: NASW Press, 2011. Childhood and Adolescence in Society: Selections From CQ Researcher. Thousand Oaks, CA: Sage, 2012. , and , eds. Immigrant Children: Change, Adaptation, and Cultural Transformation. Lanham, MD: Lexington Books, 2011. , ed. The History of Sexuality in Europe: A Sourcebook and Reader. New York: Routledge, 2011. , ed. Clinical Practice With People of Color: A Guide to Becoming Culturally Competent. New York: Teachers College Press, 2007. Dementia and Well-Being: Possibilities and Challenges. Edinburgh, UK: Dunedin, 2008. , ed. On the Stigma of Mental Illness: Practical Strategies for Research and Social Change. Washington, DC: American Psychological Association, 2005. http://dx.doi.org/10.1037/10887-000 Contesting Psychiatry: Social Movement in Mental Health. New York: Routledge, 2006. , and , eds. Handbook of Multicultural Mental Health. San Diego, CA: Academic Press, 2000. Dangerous Minds: Political Psychiatry in China Today and Its Origins in the Mao Era. New York: Human Rights Watch, 2002. The Pursuit of Oblivion: A Global History of Narcotics. New York: Norton, 2002. Towards a Sociology of Schizophrenia: Humanistic Reflections. Toronto: University of Toronto Press, 1996. , ed. Medical and Psychiatric Comorbidity Over the Course of Life. Washington, DC: American Psychiatric Publications, 2006. The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age. Montreal: McGill-Queen's University Press, 2010. , ed. Growing Up in Central Australia: New Anthropological Studies of Aboriginal Childhood and Adolescence. New York: Berghahn Books, 2011. and , eds. Culture and Mental Health: Sociocultural Influences, Theory, and Practice. Malden, MA: Wiley-Blackwell, 2009. http://dx.doi.org/10.1002/9781444305807 The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus & Giroux, 1997. and , eds. Reinventing Childhood After World War II. Philadelphia: University of Pennsylvania Press, 2012. A History of Autism: Conversations with the Pioneers. Malden, MA: Wiley-Blackwell, 2010. http://dx.doi.org/10.1002/9781444325461 Cultural Diversity, Mental Health and Psychiatry: The Struggle Against Racism. New York: Brunner-Routledge, 2003. http://dx.doi.org/10.4324/9780203420348 and , eds. History of Madness. New York: Routledge, 2006. , ed. Gender and Its Effects on Psychopathology. Washington, DC: American Psychiatric Press, 2000. and , eds. The Impact of the Environment on Psychiatric Disorder. New York: Routledge, 2008. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. Baltimore, MD: Johns Hopkins University Press, 2010. Social Work and Mental Health. Exeter, UK: Learning Matters, 2004. and . Assessment and Culture: Psychological Tests With Minority Populations. San Diego, CA: Academic Press, 2002. and . Sanity and Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem. New Haven, CT: Yale University Press, 2001. http://dx.doi.org/10.12987/yale/9780300071917.001.0001 Madness, Power and the Media: Class, Gender and Race in Popular Representations of Mental Distress. New York: Palgrave Macmillan, 2009. http://dx.doi.org/10.1057/9780230249509 Mania: A Short History of Bipolar Disorder. Baltimore, MD: Johns Hopkins University Press, 2008. The Chemical Muse: Drug Use and the Roots of Western Civilization. New York: St. Martin's Press, 2008. The Mark of Shame: Stigma of Mental Illness and an Agenda for Change. New York: Oxford University Press, 2007. and , eds. Culture and Panic Disorder. Palo Alto, CA: Stanford University Press, 2009. American Melancholy: Constructions of Depression in the Twentieth Century. New Brunswick, NJ: Rutgers University Press, 2009. Creating Mental Illness. Chicago: University of Chicago Press, 2002. and , eds. A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems. New York: Cambridge University Press, 1999. Mental Health Professionals, Minorities, and the Poor. New York: Brunner-Routledge, 2003. and , eds. Schizophrenia, Culture, and Subjectivity: The Edge of Experience. New York: Cambridge University Press, 2004. and . Genes, Environment, and Psychopathology: Understanding the Causes of Psychiatric and Substance Use Disorders. New York: Guilford Press, 2006. and , eds. The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. New York: Cambridge University Press, 2008. , ed. Mental Disorders in the Social Environment: Critical Perspectives. New York: Columbia University Press, 2005. Laing and the Paths of Anti-Psychiatry. New York: Routledge, 1997. and . The Social Psychiatry of Emotional and Behavioral Problems: Interfaces of Social and Clinical Psychology. Washington, DC: American Psychological Association, 1999. http://dx.doi.org/10.1037/10320-000 Shyness: How Normal Behavior Became a Sickness. New Haven, CT: Yale University Press, 2007. , , and , eds. Immigrant Families in Contemporary Society. New York: Guilford Press, 2007. and . Social Inclusion of People With Mental Illness. New York: Cambridge University Press, 2006. http://dx.doi.org/10.1017/CBO9780511543937 Pigeonholing Women's Misery: A History and Critical Analysis of the Psychodiagnosis of Women in the Twentieth Century. New York: Basic Books, 1996. Act Your Age! A Cultural Construction of Adolescence. New York: Routledge, 2012. Pathologies of the West: An Anthropology of Mental Illness in Europe and America. Ithaca, NY: Cornell University Press, 2002. , ed. Cultural Psychology of Immigrants. Mahwah, NJ: Lawrence Erlbaum, 2006. and , eds. Psychiatry and Empire. New York: Palgrave Macmillan, 2007. http://dx.doi.org/10.1057/9780230593244 Bipolar Expeditions: Mania and Depression in American Culture. Princeton, NJ: Princeton University Press, 2007. Black Issues in the Therapeutic Process. New York: Palgrave Macmillan, 2009. and , eds. The Sociology of Mental Illness: A Comprehensive Reader. New York: Oxford University Press, 2010. , et al., eds. Culture and Psychiatric Diagnosis: A DSM-IV Perspective. Washington, DC: American Psychiatric Press, 1996. R.D. Laing. Edinburgh, UK: Edinburgh University Press, 2004. , and . The Mental Health of Refugees: Ecological Approaches to Healing and Adaptation. Mahwah, NJ: Lawrence Erlbaum, 2004. , and , eds. Race, Culture and Psychotherapy: CriticalPerspectives in Multicultural Practice. New York: Routledge, 2006. , ed. Social Factors in Mental Health and Illness. Stamford, CT: JAI, 2000. , et al., eds. Age and Gender Considerations in Psychiatric Diagnosis. Arlington, VA: American Psychiatric Association, 2007. , ed. Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, MA: MIT Press, 2002. , ed. Global Perspectives in Family Therapy: Development, Practice, and Trends. New York: Brunner-Routledge, 2003. , , and , eds. Ethics, Culture, and Psychiatry: International Perspectives. Washington, DC: American Psychiatric Press, 2000. , , and , eds. Women's Health and Psychiatry. Philadelphia: Lippincott, Williams & Wilkins, 2002. , et al., eds. Counseling Across Cultures. 6th ed. Thousand Oaks, CA: Sage, 2008. , ed. Argentina on the Couch: Psychiatry, State, and Society, 1880 to the Present. Albuquerque: University of New Mexico Press, 2003. Balance: Advancing Identity Theory by Engaging the Black Male Adolescent. Lanham, MD: Lexington Books, 2008. and . A Sociology of Mental Health and Illness. New York: McGraw-Hill, 2010. , ed. Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs. Baltimore, MD: Johns Hopkins University Press, 2002. Values and Psychiatric Diagnosis. New York: Oxford University Press, 2005. and , eds. Cultural Cognition and Psychopathology. Westport, CT: Praeger, 2001. Working With Ethnicity, Race, and Culture in Mental Health: A Handbook for Practitioners. Philadelphia: Jessica Kingsley, 2009. Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. New Brunswick, NJ: Rutgers University Press, 2007. Empathy and Healing: Essays in Medical and Narrative Anthropology. New York: Berghahn Books, 2007. Mental Slavery: Psychoanalytic Studies of Caribbean People. London: Rebus Press, 2000. The Noonday Demon: An Atlas of Depression. New York: Scribner, 2001. Antipsychiatry: Quackery Squared. Syracuse, NY: Syracuse University Press, 2009. , ed. Social Perspectives in Mental Health: Developing Social Models to Understand and Work With Mental Distress. Philadelphia: Jessica Kingsley, 2005. In Death's Waiting Room: Living and Dying With Dementia in a Multicultural Society. Amsterdam: Amsterdam University Press, 2008. http://dx.doi.org/10.5117/9789053560778 , et al., eds. Community Mental Health: Putting Policy Into Practice Globally. Chichester, UK: Wiley-Blackwell, 2011. http://dx.doi.org/10.1002/9781119979203 Naughty Boys: Anti-Social Behavior, ADHD, and the Role of Culture. New York: Palgrave Macmillan, 2005. The Age of Anxiety: A History of America's Turbulent Affair With Tranquilizers. New York: Basic Books, 2009. and . The Invisible Plague: The Rise of Mental Illness From 1750 to the Present. New Brunswick, NJ: Rutgers University Press, 2001. , , and , eds. Asian Culture and Psychotherapy: Implications for East and West. Honolulu: University of Hawai‘i Press, 2005. Asian Americans: Personality Patterns, Identity, and Mental Health. New York: Guilford Press, 1994. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, 2010. and . Broken Spirits: The Treatment of Traumatized Asylum Seekers, Refugees, War, and Torture Victims. New York: Brunner-Routledge, 2004. Women and Borderline Personality Disorder: Symptoms and Stories. New Brunswick, NJ: Rutgers University Press, 2001. Inventing the Addict: Drugs, Race, and Sexuality in Nineteenth-Century British and American Literature. Amherst: University of Massachusetts Press, 2008. Journals Addiction Research & Theory Addictive Behaviors Annual Review of Clinical Psychology Applied and Preventive Psychology Applied Social Psychology Annual Asian Journal of Social Psychology Autism Autism Research British Journal of Clinical Psychology British Journal of Psychiatry British Journal of Social and Clinical Psychology Child & Youth Services Clinical Psychology Clinical Psychology Review Communication & Medicine Cultural Diversity & Mental Health Culture, Medicine, and Psychiatry Culture & Psychology Epidemiology and Community Health Ethos European Child and Adolescent Psychiatry European Journal of Social Psychology European Psychiatry Evidence-Based Mental Health Health Psychology Health Sociology Review International Journal of Social Psychiatry International Perspectives in Psychology: Research, Practice, Collaboration Journal of Adolescence Journal of Adolescent Research Journal of Autism and Developmental Disorders Journal of Community Psychology Journal of Consulting and Clinical Psychology Journal of Cross-Cultural Psychology Journal of Ethnicity in Substance Abuse Journal of Health and Social Behavior Journal of Health & Social Policy Journal of Personality and Social Psychology Journal of Research on Adolescence Journal of Social and Clinical Psychology Journal of Substance Abuse Treatment Medical Anthropology Medical Anthropology Quarterly Medical Social Work Open Addiction Journal Research in Autism Spectrum Disorders Social Psychiatry and Psychiatric Epidemiology Social Science & Medicine Society and Mental Health Sociology of Health & Illness Transcultural Psychiatry World Cultural Psychiatry Research Review World Psychiatry Web Sites American Association for Social Psychiatryhttp://www.socialpsychiatry.org American Institute for Learning and Human Development, Neurodiversity http://www.institute4learning.com/neurodiversity.php American Psychiatric Association, LGBT-Sexual Orientationhttp://www.psychiatry.org/mental-health/people/lgbt-sexual-orientation American Psychoanalytic Associationhttp://www.apsa.org American Psychological Association, Section on International Psychologyhttp://www.apa.org/about/division/div.aspx American Psychological Association, Society for Community Research and Action: Division of Community Psychologyhttp://www.apa.org/about/division/div.aspx American Sociological Association, Section on Sociology of Mental Healthhttp://www.asanet.org/sections/mentalhealth.cfm British Sociological Association, Medical Sociology Study Grouphttp://www.britsoc.co.uk/medical-sociology.aspx Centers for Disease Control and Prevention, Mental Healthhttp://www.cdc.gov/mentalhealth Citizens Commission on Human Rights, Mental Health Declaration of Human Rightshttp://www.cchr.org/about-us/mental-health-declaration-of-human-rights.html European Brain Council, Resourceshttp://www.europeanbraincouncil.org/resources Foundation for the Sociology of Health and Illnesshttp://www.shifoundation.org.uk International Association for Cross-Cultural Psychologyhttp://www.iaccp.org Mental Health Americahttp://www.nmha.org Mental Health Commission of Canada, Partners for Mental Healthhttp://www.mentalhealthcommission.ca/English/Pages/PartnersforMentalHealth.aspx Movement for Global Mental Healthhttp://www.globalmentalhealth.org National Asian American Pacific Islander Mental Health Associationhttp://naapimha.org National Institute of Mental Health, Statisticshttp://www.nimh.nih.gov/statistics/index.shtml National Library of Medicine, Mental Healthhttp://www.nlm.nih.gov/medlineplus/mentalhealth.html Social Psychology Network: Cultural Psychologyhttp://www.socialpsychology.org/cultural.htm Society for the Study of Psychiatry and Culturehttp://www.psychiatryandculture.org U.S. Department of Health and Human Services, Office of Minority Health, Mental Health Data/Statisticshttp://minorityhealth.hhs.gov/templates/ browse.aspx?lvl=3&lvlid=539 U.S. Department of Veterans Affairs, Mental Healthhttp://www.mentalhealth.va.gov World Federation for Mental Health http://www.wfmh.org/00WorldMentalHealthDay.htm World Health Organization, Mental Healthhttp://www.who.int/mental_health/en World Psychiatric Associationhttp://www.wpanet.org Sarah Boslaugh Kennesaw State University Journals Addiction Research & Theory Addictive Behaviors Annual Review of Clinical Psychology Applied and Preventive Psychology Applied Social Psychology Annual Asian Journal of Social Psychology Autism Autism Research British Journal of Clinical Psychology British Journal of Psychiatry British Journal of Social and Clinical Psychology Child & Youth Services Clinical Psychology Clinical Psychology Review Communication & Medicine Cultural Diversity & Mental Health Culture, Medicine, and Psychiatry Culture & Psychology Epidemiology and Community Health Ethos European Child and Adolescent Psychiatry European Journal of Social Psychology European Psychiatry Evidence-Based Mental Health Health Psychology Health Sociology Review International Journal of Social Psychiatry International Perspectives in Psychology: Research, Practice, Collaboration Journal of Adolescence Journal of Adolescent Research Journal of Autism and Developmental Disorders Journal of Community Psychology Journal of Consulting and Clinical Psychology Journal of Cross-Cultural Psychology Journal of Ethnicity in Substance Abuse Journal of Health and Social Behavior Journal of Health & Social Policy Journal of Personality and Social Psychology Journal of Research on Adolescence Journal of Social and Clinical Psychology Journal of Substance Abuse Treatment Medical Anthropology Medical Anthropology Quarterly Medical Social Work Open Addiction Journal Research in Autism Spectrum Disorders Social Psychiatry and Psychiatric Epidemiology Social Science & Medicine Society and Mental Health Sociology of Health & Illness Transcultural Psychiatry World Cultural Psychiatry Research Review World Psychiatry Web Sites American Association for Social Psychiatryhttp://www.socialpsychiatry.org American Institute for Learning and Human Development, Neurodiversityhttp://www.institute4learning.com/neurodiversity.php American Psychiatric Association, LGBT-Sexual Orientationhttp://www.psychiatry.org/mental-health/people/lgbt-sexual-orientation American Psychoanalytic Associationhttp://www.apsa.org American Psychological Association, Section on International Psychologyhttp://www.apa.org/about/division/div.aspx American Psychological Association, Society for Community Research and Action: Division of Community Psychologyhttp://www.apa.org/about/division/div.aspx American Sociological Association, Section on Sociology of Mental Healthhttp://www.asanet.org/sections/mentalhealth.cfm British Sociological Association, Medical Sociology Study Grouphttp://www.britsoc.co.uk/medical-sociology.aspx Centers for Disease Control and Prevention, Mental Healthhttp://www.cdc.gov/mentalhealth Citizens Commission on Human Rights, Mental Health Declaration of Human Rightshttp://www.cchr.org/about-us/mental-health-declaration-of-human-rights.html European Brain Council, Resourceshttp://www.europeanbraincouncil.org/resources Foundation for the Sociology of Health and Illnesshttp://www.shifoundation.org.uk International Association for Cross-Cultural Psychologyhttp://www.iaccp.org Mental Health Americahttp://www.nmha.org Mental Health Commission of Canada, Partners for Mental Healthhttp://www.mentalhealthcommission.ca/English/Pages/PartnersforMentalHealth.aspx Movement for Global Mental Healthhttp://www.globalmentalhealth.org National Asian American Pacific Islander Mental Health Associationhttp://naapimha.org National Institute of Mental Health, Statisticshttp://www.nimh.nih.gov/statistics/index.shtml National Library of Medicine, Mental Healthhttp://www.nlm.nih.gov/medlineplus/mentalhealth.html Social Psychology Network: Cultural Psychologyhttp://www.socialpsychology.org/cultural.htm Society for the Study of Psychiatry and Culturehttp://www.psychiatryandculture.org U.S. Department of Health and Human Services, Office of Minority Health, Mental Health Data/Statisticshttp://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=539 U.S. Department of Veterans Affairs, Mental Health http://www.mentalhealth.va.gov World Federation for Mental Health http://www.wfmh.org/00WorldMentalHealthDay.htm World Health Organization, Mental Healthhttp://www.who.int/mental_health/en World Psychiatric Associationhttp://www.wpanet.org ## Appendix: Federal Reports on Mental Illness Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report September 2, 2011: Mental Illness Surveillance Among Adults in the United States Mental Illness Surveillance Among Adults in the United States 1 1 2 3 3 4 3 3 3 3 3 1 5 1Public Health Surveillance Program Office 2National Center for Health Statistics 3National Center for Chronic Disease Prevention and Health Promotion 4Northrop Grumman 5National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Summary Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previous year. The economic cost of mental illness in the United States is substantial, approximately$300 billion in 2002. Population surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug abuse) and chronic conditions, and use of mental health–related care and clinical services. Population-based surveys and surveillance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and treatment programs.

This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental illness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005–2008 National Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007–2008, approximately 5% of ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depression, psychoses, or anxiety disorders.

Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and use of mental health treatment services could substantially reduce the associated morbidity.

Introduction

Mental illness refers collectively to all diagnosable mental disorders and is characterized by sustained, abnormal alterations in thinking, mood, or behavior associated with distress and impaired functioning (1). Mental illness is an important public health problem, both in its own right and because the condition is associated with other chronic diseases and their resulting morbidity and mortality. According to the World Health Organization (WHO), mental illnesses account for more disability in developed countries than any other group of illnesses, including cancer and heart disease (2). Approximately one fourth of adults in the United States have a mental illness, and nearly half will develop at least one mental illness during their lifetime (3–5). The most common mental illnesses in adults are anxiety and mood disorders (4). The effects of mental illness range from minor disruptions in daily functioning to incapacitating personal, social, and occupational impairments and premature death (6–9). In 2002 and 2003, mental illness cost the United States an estimated $300 billion annually, which included approximately$193 billion from lost earnings and wages and $24 billion in disability benefits in 2002 (10) and$100 billion in health-care expenditures in 2003 (11).

Mental illness exacerbates morbidity from the multiple chronic diseases with which it is associated, including cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer (12–16). This increased morbidity is a result of lower use of medical care and treatment adherence for concurrent chronic diseases and higher risk for adverse health outcomes (17–20). Rates for injuries, both intentional (e.g., homicide and suicide) and unintentional (e.g., motor vehicle), are 2–6 times higher among persons with a mental illness than in the overall population (21,22). Mental illness also is associated with use of tobacco products and alcohol abuse (23).

This report summarizes data from selected CDC surveillance and information systems that measure mental illness and the associated effects in the U.S. adult population. The data presented include 1) the occurrence and associated effects of mental illness among adults in the United States as measured through selected CDC surveillance and information systems, 2) the CDC systems involved in the collection of mental illness data for adults and the associated public access databases, and 3) estimates from other studies and surveys, particularly those conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), compared with CDC system estimates.

Background
Role of Surveillance in Reducing Morbidity and Mortality Associated with Mental Illness

Public health surveillance is the ongoing and systematic collection, analysis, interpretation, and dissemination of data used to develop public health interventions that reduce morbidity and mortality and improve health (24). Surveillance for a particular condition might depend either on collection of new data or use of data obtained from existing health information systems (e.g., from vital statistics or public health surveys). Surveillance data have numerous uses in public health: 1) determination of the distribution and spread of disease, 2) estimation of the impact of a disease or injury, 3) generation of hypotheses and stimulation of research, 4) development of public health interventions, 5) description of the history of a health condition and the impact of treatments on outcomes, 6) evaluation of prevention and control measures, and 7) facilitation of program planning (25). Because a single surveillance system typically cannot accomplish all of these tasks, use of multiple surveillance systems often provides a more complete assessment of a particular disease or condition.

Surveillance data are essential to the public health goals of reducing the incidence, prevalence, severity, and economic impact of mental illnesses. Public health officials, academicians, health-care providers, and advocacy groups need accurate and timely information on the prevalence and effects of mental illness to detect and characterize trends in mental illness prevalence and severity (26); assess associations between mental illness and other chronic medical conditions (e.g., obesity, diabetes, heart disease, and alcohol and substance abuse); identify populations at high risk for mental illness and target interventions, treatment, and prevention measures; and provide outcome measures for evaluating mental illness interventions. For example, officials have used metal illness surveillance data to track trends in mental illness and psychological distress associated with exposure to military combat or large-scale disasters (27).

Diagnostic Classification of Mental Illness

Population surveys can be used to estimate accurately the prevalence of certain mental illness symptoms across populations, and by repeating surveys over time, they can be used to detect and characterize trends. Surveys generally cannot be used to diagnose mental disorders with the same level of specificity as an individual clinical examination conducted by an experienced psychiatrist or other mental health professional. Instead, they collect information on a range of subjective manifestations of alterations in thinking, mood, behavior, and associated distress that correspond with clinical disorders. Surveys collect this information using participant questionnaires that have been validated empirically to distinguish between persons with and without specific mental illnesses or general psychological distress. Estimates from these surveys vary according to the symptoms being collected and the way they correspond with various defined mental illnesses. Survey estimates usually are based on carefully defined patterns of symptoms. The most commonly used patterns correspond with diagnostic criteria agreed on by mental health professionals.

The symptom patterns used for surveys vary according to the classification of mental illness under study; changes in these classifications over time have increased the complexity of matching symptom patterns to specific illnesses. New classifications have been identified, and certain classifications have been removed. Even for relatively stable diagnostic categories (e.g., depression), subcategories and terminology have varied over time. For example, terms used to describe depression have included major and minor depression, psychotic depression, depression not otherwise specified, bipolar disorder, dysthymia, moderate to severe depression, and mild depression. However, the relationship among the disorders described by these different terms often is unclear. The American Psychiatric Association (APA) developed mental illness diagnostic categories based on symptoms observed by a health professional or reported by the patient; the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is the current version of this system (28). Another system, the WHO International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), defines mental illness categories that are similar but not identical to those in the DSM-IV-TR (29). Previous DSM and ICD versions have not been completely congruent, and APA is developing a fifth edition of the DSM (DSM-V) that will coordinate better with future editions of ICD (30).

Methods for Measuring Prevalence and Public Health Impact of Mental Illness
Research Instruments

The Structured Clinical Interview for DSM Disorders (SCID) Research Version (31) is considered to be the standard among psychiatric research instruments based on DSM-IV-TR criteria; however, SCID takes 30–60 minutes and must be conducted by a trained mental health professional. Another instrument, the Composite International Diagnostic Interview (CIDI), was developed by WHO and is based on ICD-10 mental illness criteria. CIDI also is intended for use in epidemiological, clinical, and research studies. CIDI is lengthy, like SCID, but may be administered by trained lay interviewers (32). SCID and CIDI identify overlapping but not necessarily identical populations because they are based on different classification systems.

Screening Instruments

Large surveys that focus on a wide range of health topics typically can include only a limited number of mental health questions and often rely on SCID- or CIDI-validated screening instruments to provide indicators of psychiatric-related symptoms; in some cases, statistical models are used to predict the likelihood of specific mental illness in the respondent based on rating scales. Several standardized and validated screening instruments can be used to identify persons with mental illnesses such as depression and psychological distress, with varying degrees of diagnostic sensitivity and specificity (33–35). CDC surveys use these screening instruments, as well as other standardized questions, to assess mental illness and other measures, such as impaired quality of life (e.g., mentally unhealthy days) and health-related disability associated with mental illness.

Depression (Patient Health Questionnaire-8 and Patient Health Questionnaire-9)

Depression is a major focus of population surveys of mental illness. To meet the DSM-IV-TR definition of major depressive disorder, a person must have either a depressed mood or a loss of interest or pleasure in daily activities consistently for at least 2 weeks. This mood must represent a change from the person's normal mood; social, occupational, educational, or other important functioning also must be impaired by the change in mood. Under the DSM-IV-TR, a depressed mood that is caused by substances (e.g., drugs, alcohol, or medications) or that is part of a general medical condition is not considered to be major depressive disorder (28).

One of the most widely used and validated instruments for measuring depression in population surveys is the nine-item Patient Health Questionnaire (PHQ-9). The PHQ-9 screens for the presence of the nine DSM-IV-TR criteria for acute and clinically significant depressive disorders (36). A PHQ-9 score of ≥10 has high sensitivity (88%) and specificity (88%) when validated against SCID (37) and effectively detects depressive symptoms among persons of various races and ethnicities (38,39). The PHQ-9 has been used as a self-administered module in many clinical studies and telephone-administered surveys (38,40–43).

Other telephone surveys have used a slightly shorter instrument, the eight-item Patient Health Questionnaire (PHQ-8), which omits the PHQ-9 question concerning suicidal or self-injurious ideation because survey administrators might not be able to offer appropriate follow-up interventions. Omitting this question in population-based surveys has only a minor effect on the usefulness of PHQ as a screen for depression (36).

The standard PHQ-8 and PHQ-9 have the following primary question: “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The following problems are listed: 1) little interest or pleasure in doing things; 2) feeling down, depressed, or hopeless; 3) trouble falling/staying asleep, sleeping too much; 4) feeling tired or having little energy; 5) poor appetite or overeating; 6) feeling bad about yourself or that you are a failure or have let yourself or your family down; 7) trouble concentrating on things, such as reading the newspaper or watching television; 8) moving or speaking so slowly that other people could have noticed, or the opposite—being so fidgety or restless that you have been moving around a lot more than usual; and 9) (PHQ-9 only) thoughts that you would be better off dead or of hurting yourself in some way. Response categories are “not at all,” “several days,” “more than half the days,” and “nearly every day.”

PHQ-8 and PHQ-9 answers are scored using one of two algorithms, and the scores are used to assign depression categories. One algorithm is based on the DSM-IV and categorizes depressed respondents as having a major depressive disorder or other depression. The other algorithm categorizes respondents according to the severity of depressive symptoms (i.e., no significant depressive symptoms or mild, moderate, moderately severe, or severe depressive symptoms) (36,37).

Psychological Distress (Kessler-6 Psychological Distress Scale)

Surveys use the Kessler-6 psychological distress scale to screen for psychological distress experienced by persons with anxiety and mood disorders (44). The Kessler-6 scale asks respondents about the frequency with which they have experienced six manifestations of psychological distress, which include feeling 1) nervous, 2) hopeless, 3) restless or fidgety, 4) so sad or depressed that nothing could cheer the respondent up, 5) that everything is an effort, and 6) worthless. Responses are “all of the time,” “most of the time,” “some of the time,” “a little of the time,” and “none of the time.” Scoring of individual items is based on a 4-point scale according to increased frequency of the problem, yielding a total six-item score ranging from 0–24. A score of ≥13 indicates serious psychological distress (45). Serious psychological distress as defined by the Kessler-6 score is highly associated with anxiety disorders and depression but does not identify a specific mental illness (44).

Mentally Unhealthy Days

Health-related quality of life (HRQOL) is a multidimensional concept that includes physical, mental, emotional, and social domains and reflects perceived physical and mental health (46,47). HRQOL often is used to characterize certain aspects of disease impact, disability, and injury and to identify unmet health needs and disparities among various sociodemographic populations (48). A core set of four questions (i.e., the Healthy Days Core Module, or HRQOL-4) has been standardized and validated for public health survey purposes. HRQOL-4 asks respondents about self-rated general health, physical health, mental health, and activity limitations resulting from poor physical or mental health during the previous 30 days (48). One indicator often used to measure HRQOL is the number of mentally unhealthy days experienced by a person. Typically, the question asks: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Respondents who report ≥14 mentally unhealthy days over the past month are defined as having frequent mental distress. The mentally unhealthy days question has acceptable criterion validity and test-retest reliability (48–50). In a large prospective study, this question predicted 1-month and 12-month physician visits, hospitalizations, and mortality outcomes (51).

Health-Care Surveys

Data from health-care providers and insurers provide an additional important source of information on the prevalence of mental illness in the United States. Coding systems used by hospitals and medical providers for billing purposes typically use the ICD-9 coding system, which, as mentioned previously, is not completely congruent with the DSM-IV-TR. In addition, mental health professionals generally use the DSM-IV-TR nomenclature, whereas primary care providers use other terminology. In practice, regardless of the diagnostic system used, diagnoses vary according to the training of the coder, local practice, availability of treatment resources, and reimbursement codes.

CDC Surveillance Systems and Surveys That Measure Prevalence and Impact of Mental Illness

CDC systems for measuring the prevalence and impact of mental illness in the U.S. adult population fall into two categories: 1) population surveys, which are used to estimate mental illness prevalence, and 2) national health-care surveys that include a diagnosed psychiatric condition based on ICD-9 codes, which are used to estimate outpatient visits and hospitalizations and reflect access to and use of health care by persons with mental illness (Table 1). Both of these systems provide public access data sets that allow researchers to address specific queries or conduct specific analyses. In combination with information from other studies and surveys, notably surveys conducted by SAMHSA, data from these CDC systems can be used to plan, implement, and evaluate mental illness prevention strategies and to explore ways to protect and promote mental health. Proper interpretation of mental health surveillance statistics requires an understanding of 1) the reason the data were collected (e.g., to identify prevalence or for program planning); 2) the survey population (e.g., representative of state or national population, sample frame, and time conducted); 3) survey methods (e.g., telephone vs. in-person interviews, record reviews or abstracts, and vital statistics); 4) questionnaires and questions used (e.g., standardization, validity, and reliability); 5) parameters measured (population prevalence and effects of the illness); and 6) appropriate analyses (adjustment and weighting for survey designs and response rates, rates, proportions, and continuous measures).

Population Surveys
BRFSS

BRFSS is a state-based telephone survey that was established in 1984.* BRFSS is the largest ongoing telephone health survey in the world, with approximately 450,000 adult interviews completed each year. BRFSS collects standardized, state-specific data concerning preventive health practices and risk behaviors associated with infectious diseases, chronic diseases, and injuries in the adult population. Data are collected in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. The large size of the survey permits calculation of state-specific estimates (and in some cases, substate estimates) and aggregated nationwide estimates. States use BRFSS data to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs. For many states, BRFSS is the only source of timely, accurate, state-based data on health-related behaviors.

BRFSS interviews consist of three parts: 1) core questions asked in all states and territories (e.g., demographics, HRQOL, access to health care, disability, chronic conditions, and risk behaviors); 2) optional modules with questions on specific topics (for mental illness: the anxiety and depression module and the mental illness and stigma module); and 3) questions added by individual states. BRFSS data are directly weighted for the probability of selection of a telephone number, the number of adults in a household, and the number of landline telephone numbers that reach a household. Data are then stratified to adjust for nonresponse, to adjust for noncoverage of households without telephones, and to force the sum of the weighted frequencies to equal the adult population in each state.

Every year, the core BRFSS includes a question on number of mentally unhealthy days as a measure of HRQOL. States also may administer BRFSS optional modules (conducted through a collaboration between CDC and SAMHSA) that address other mental health topics in depth. In 2006, 2008, and 2010, an optional BRFSS module on anxiety and depression contained the PHQ-8, one question on lifetime diagnosis of anxiety, and one question on lifetime diagnosis of depression. In 2007 and 2009, an optional BRFSS module on mental illness and stigma included the Kessler-6 scale (past 30 days), one question on activity limitations associated with a mental health condition or emotional problem, one question on treatment, and two questions on attitudes toward mental illness that might underlie stigma. Because certain individual states do not use these optional modules, BRFSS cannot provide national estimates of depression or psychological distress.

CDC provides public online access to the following summary statistics from various BRFSS modules:

• Prevalence and trends data: prevalence estimates for core variables by year and by state from 1995 to the present
• Selected metropolitan/micropolitan area risk trends (SMART) city and county data: CDC information on all health risk data for metropolitan and micropolitan statistical areas (MMSAs) by year and category, with users able to generate reports that compare statistics by MMSA and to use SMART to produce charts that show state, MMSA, and county data for a limited set of health risk factors (2002–2008)§,
• BRFSS maps: MMSA maps for many core variables (2002–present)** and annual BRFSS survey data and technical documentation so that researchers can conduct their own analyses
• Yearly state-based survey data sets and technical documentation (1984–present)††
• Yearly data sets and technical documentation for counties and MMSAs with ≥500 respondents (2002–present)§§
• Yearly data and technical documentation for state and MMSA geographic information system data files (2002–present)¶¶
National Health Interview Survey

NHIS uses a multistage area probability design to identify representative U.S. households. The sample is redesigned and redrawn approximately every 10 years to more accurately measure the changing population and to meet new survey objectives. NHIS oversamples blacks, Hispanics, and Asians (especially those aged ≥65 years) to allow for more precise estimation of health characteristics in these growing minority populations. The NHIS sample size (approximately 10,000) is not sufficient to provide reliable state-level estimates for most states. Although the database does not identify respondents' state of residence, state-level estimates can be produced for more populous states by requesting state identifiers through the CDC National Center for Health Statistics (NCHS) Research Data Centers.†††

NHIS sample weights, which account for the differential probabilities of selection, nonresponse, and noncoverage, must be used for all analyses. Methods that incorporate the complex sample design and weights (e.g., Taylor series linearization) must be used to calculate appropriate standard errors.

Since 1997, NHIS has used the Kessler-6 scale (past 30 days) to identify serious psychological distress among adults. National rates for psychological distress by age, sex, and race are produced quarterly through the NHIS Early Release Program and are available online. In 2007, the NHIS included three questions on lifetime diagnoses: “Have you EVER been told by a doctor or other health professional that you had bipolar disorder? Schizophrenia? Mania or psychoses?”

National Health and Nutrition Examination Survey

The National Health and Nutrition Examination Survey (NHANES) is a continuous survey of the health and nutritional status of the U.S. civilian noninstitutionalized population.§§§ Although NHANES uses a multistage probability household sampling design to obtain a nationally representative sample, the sample is not sufficient for state- or local-level analyses. NHANES sample weights, which account for the differential probabilities of selection, nonresponse, and noncoverage, must be used for all analyses. Survey participants complete an interview administered in their home and then are invited to participate in an examination conducted in a mobile examination center. This includes a private interview, a standardized physical examination, and collection of biological specimens for laboratory testing. NHANES collects data on the prevalence of 1) chronic diseases and conditions (including undiagnosed conditions detected through the examination or laboratory testing) and risk factors (e.g., obesity, smoking, serum cholesterol levels, hypertension, and diet and nutritional status), 2) vaccination status, 3) infectious disease prevalence, 4) health insurance, and 5) measures of environmental exposures. Other topics include hearing, vision, anemia, diabetes, cardiovascular disease, osteoporosis, oral health, pharmaceuticals and dietary supplements, physical fitness, HRQOL, and health-care use. In the private mobile examination center interview, NHANES uses the PHQ-9 to measure depression, and since 2000, this NHANES interview also has included the question on number of mentally unhealthy days. The examination and laboratory data collected allow researchers to examine the relationships between depression and health variables not available on other national surveys.

Pregnancy Risk Assessment Monitoring System

The Pregnancy Risk Assessment Monitoring System (PRAMS) was established in 1987 and is a state-based, cross-sectional survey of women who have recently delivered a live-born infant. PRAMS provides population-based data that can be used to develop maternal and infant health programs and policies.¶¶¶ The survey uses a mixed-mode data collection method. Each month, randomly selected women who have delivered a live-born infant are requested to complete a mail questionnaire; follow-up with nonresponders occurs by phone. Data are collected in 37 states and New York City, representing approximately 75% of the births in the United States. Data are weighted to adjust for survey design, nonresponse, and noncoverage.

PRAMS collects information on maternal behaviors, attitudes, and experiences before, during, and after pregnancy. Survey responses are linked to birth certificate data. The questionnaire includes core questions asked of all participants in all states, optional standard questions pretested by CDC, and state-developed questions. PRAMS provides estimates of postpartum depression by using two questions similar to those included in the PHQ-8: 1) “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and 2) “Since your new baby was born, how often have you had little interest in doing things?” Possible responses are “never,” “rarely,” “sometimes,” “often,” and “always.” Women who answer “often” or “always” to either question or both questions are categorized as having postpartum depression.

CDC provides access to PRAMS data electronically through CPONDER (CDCs PRAMS On-line Data for Epidemiologic Research).**** CPONDER provides access to prevalence estimates by state and by year (2000–2008). In addition, CPONDER indexes 54 variables by topic for selection as the outcome variable in cross-tabular analyses. Twelve control variables may be used to stratify these outcomes in an analysis. Analyses may include a single state and all available years or all available states and a single year.

National Health-Care Surveys

CDC conducts surveys of health-care providers, and the data from these surveys complement data from the population-based surveys to provide a more complete representation of the occurrence of mental illness in the United States. For the health-care surveys, CDC collects data from a sample of organizations that provide health care (e.g., nursing homes, inpatient hospitals, or physician offices). The data can be used to examine factors that influence use of health-care resources, quality of health care, and disparities in health-care services in population subgroups. In addition, because the surveys collect core information from a sample of providers that remains relatively stable over time, trends in the types of care delivered in each setting can be monitored and examined in relation to the characteristics of providers, patients, and clinical management of patient care.

National Ambulatory Medical Care Survey

The National Ambulatory Medical Care Survey (NAMCS)†††† collects information on the use of ambulatory care services in the United States. NAMCS uses a multistage probability sample of visits to office-based physicians and health-care providers in community health centers and collects data on provider characteristics. Sample data are weighted to produce national estimates that describe the provision and use of ambulatory medical care services in the United States. Public use data files are released annually and include a visit statistical weight and (since 2005) a physician statistical weight. Information on mental health and mental illness available from NAMCS includes reasons for visit, physician diagnosis, medications, treatment, referrals, and one item on comorbid depression. Physician diagnoses are recorded as written by the physician (text or ICD-9 codes). Nosologists convert text to ICD-9 codes for the data files.

National Hospital Ambulatory Medical Care Survey

The National Hospital Ambulatory Medical Care Survey (NHAMCS)†††† collects data on the use of ambulatory care services in hospital emergency and outpatient departments. NHAMCS involves a multistage probability sample of visits to the emergency and outpatient departments of noninstitutional, general, and short-stay hospitals in the United States. Federal, military, and U.S. Department of Veterans Affairs hospitals are not included. Data collected from outpatient departments are similar to those collected by NAMCS. Data from emergency department visits are slightly different from the outpatient department data and include whether the patient was admitted to a mental health unit or transferred to a psychiatric hospital. Sample data are weighted to produce national estimates. Public-use data files are released annually.

National Hospital Discharge Survey

The National Hospital Discharge Survey (NHDS)§§§§ obtains national-level information on characteristics of inpatients discharged from nonfederal, short-stay (<30 days) hospitals in the United States. Only hospitals with an average length of stay of <30 days, general hospitals, and children's general hospitals are included in the survey. Psychiatric hospitals with an average length of stay of <30 days are eligible. NHDS does not include federal, military, U.S. Department of Veterans Affairs hospitals, prison hospitals, or hospitals with fewer than six beds. Hospitals are selected by using a three-stage stratified design. Patient information collected includes demographics, length of stay, diagnoses, and procedures. Hospital characteristics collected include region, ownership, and number of beds. NHDS sample statistical weights account for nonresponse and must be used for all analyses. Methods that incorporate the complex sample design and weights, such as Taylor series linearization, must be used to calculate appropriate standard errors.

National Nursing Home Survey

The National Nursing Home Survey (NNHS)¶¶¶¶ is a continuous series of national sample surveys of nursing homes and their residents and staff members. NNHS provides information on nursing homes from the perspectives of the provider and recipient of services. Data on facilities include characteristics such as number of beds, ownership, affiliation, Medicare and Medicaid certification, specialty units, services offered, number and characteristics of staff, expenses, and charges. Data on current residents include demographic characteristics, health status, up to 16 current diagnoses, level of assistance needed with activities of daily living, vision and hearing impairment, continence, services received, and sources of payment. The survey uses a stratified two-stage probability design. The first stage is the selection of facilities, and the second stage is selection of residents.

Findings from CDC Surveillance Systems and Surveys

Through the surveys and surveillance systems described in this report, CDC provides prevalence estimates on current depression, postpartum depression, psychological distress, number of mentally unhealthy days, and lifetime diagnosis of depression, anxiety, bipolar disorder, and schizophrenia in the U.S. adult population. CDC health-care surveys provide health services information about physician, hospital outpatient, and emergency department visits related to mental illness. All of these CDC systems can provide data for national-level (or nationwide) estimates by sex, age, race, and ethnicity. BRFSS and PRAMS data also can be used for state-level estimates.

Population Surveys
Current Depression

Two CDC surveillance systems provide estimates for current depression: NHANES (national estimates) and BRFSS (state estimates). These systems use the PHQ-9 (NHANES) or PHQ-8 (BRFSS) to estimate the occurrence of depression in the last 2 weeks. For example, using continuously collected data from 2005–2008 (the most recent data available), results from NHANES indicate that 6.8% of U.S. adults had depression (measured by the PHQ-9) during the 2 weeks before the survey (Table 2).

Results from BRFSS for current depression (measured by the PHQ-8) vary according to the year conducted because in different years, a varying number of states might have administered the optional modules containing the mental illness–related questions. Results from 2006 (in 38 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands) using the PHQ-8 indicate that approximately 8.7% of respondents had current depression. Results from 2008 in 16 states using the optional BRFSS anxiety and depression module indicate that 8.2% had current depression. Prevalence estimates were higher among women and non-Hispanic blacks compared with other groups (Table 3).

Using the PHQ-8 algorithm for major depressive disorder (36), the 2006 BRFSS prevalence estimate of major depression during the previous 2 weeks was 3.5% (95% confidence interval [CI]: 3.3–3.7) and in 2008 was 3.0% (95% CI: 2.8–3.3). BRFSS state-specific prevalence estimates for depression in 2006 and 2008 show marked variations from state to state, with prevalences ranging from 4.3% in North Dakota to 13.7% in Mississippi and West Virginia (Table 4). The prevalence of depression was generally highest in the southeastern states (Figure 1).

Postpartum Depression

During 2004–2008, a total of 14.5% of PRAMS respondents reported symptoms of postpartum depression (i.e., answered “often” or “always” to either or both of the following questions): 1) “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and 2) “Since your new baby was born, how often have you had little interest in doing things?”) (Table 5). The prevalence of postpartum depression varied by age, ranging from 10.3% among women aged 30–39 years to 23.3% among women aged ≤19 years. Prevalence also varied by race/ethnicity: 16.8% among Hispanic women, 11.9% among non-Hispanic white women, and 21.5% among non-Hispanic black women. Among 22 states, the prevalence of postpartum depression ranged from 9.8% in Minnesota to 21.3% in Tennessee (Table 6).

Psychological Distress

Both NHIS and optional modules of BRFSS use the Kessler-6 scale to identify persons who experienced psychological distress during the 30 days before the survey. NHIS data indicate that in 2009, 3.2% of respondents experienced serious psychological distress (Table 7). BRFSS included the Kessler-6 in the optional mental illness and stigma module during 2007 (administered in 35 states, the District of Columbia, and Puerto Rico) and 2009 (16 states). Among participating states, prevalence estimates were similar in 2007 (4.0%) and 2009 (3.9%) (Table 8). These BRFSS estimates are higher than NHIS estimates, which might be a result of the limited geographical coverage of BRFSS, differences in survey design and methods, question placement, and context. As in NHIS, women were more likely to have serious psychological distress than men, and rates were highest among adults aged 45–54 years and non-Hispanic blacks. BRFSS data for state-specific prevalences of serious psychological distress during 2007 and 2009 indicate that, like depression, prevalence varied among states, ranging from 1.9% in Utah to 9.4% in Tennessee (Table 9). The prevalence of serious psychological distress was generally highest in the southeastern states (Figure 2).

Mentally Unhealthy Days

The question on number of mentally unhealthy days is included in the BRFSS core questionnaire; therefore, data are available for every year for all states and territories. Nationwide, for 2009, adults aged ≥18 years reported an average of 3.5 mentally unhealthy days during the past 30 days (Table 10). Among states, in 2009, the median number of mentally unhealthy days was 3.4, and the 25th and 75th quartiles were 3.1 and 3.7 days, respectively (Table 11). The mean number of mentally unhealthy days was highest in the southeastern states (Figure 3).

The BRFSS optional anxiety and depression module includes questions on whether respondents have received a diagnosis of depression or anxiety disorder in their lifetime. Although the number of participating states varied between the 2 years in which the module was administered, rates of reported lifetime diagnosis of depression were similar in 2006 (15.7%) and 2008 (16.1%) (Tables 12 and 13). The prevalence of lifetime diagnosis of anxiety disorders was slightly lower, with 11.3% in 2006 and 12.3% in 2008 (Tables 14 and 15). In 2007, NHIS included a question for all respondents on lifetime diagnosis of bipolar disorder and schizophrenia; 1.7% of participants had received a diagnosis of bipolar disorder, and 0.6% had received a diagnosis of schizophrenia (Table 16).

National Health-Care Surveys
NAMCS and NHAMCS

During 2007–2008, an estimated 47.8 million ambulatory care visits were made by patients with primary mental health diagnoses, which constituted approximately 5% of all ambulatory care visits made in the United States during those 2 years (Tables 17 and 18). Women made 29.4 million of the visits, compared with 18.5 million for men. Of all mental illness–related visits, the greatest proportion of visits (31%) were made by patients with any depressive disorder, followed by 23% of visits among those with schizophrenia and other psychotic disorders. The proportion of visits related to alcohol and drug use that occurred in emergency and outpatient departments was higher than the proportion of visits for other mental illness diagnoses.

NHDS

Among patients discharged from nonfederal, short-stay hospitals, mental illness was a primary diagnosis for 97.9 discharged patients per 10,000 population among persons aged 18–64 years. The occurence decreased with age to 64.4 among those aged ≥65 years (Table 19). Mood disorders were the most common primary mental illness discharge diagnosis, and the occurence decreased with age, with a range of 46.0 per 10,000 population among patients aged 18–44 years to 19.2 per 10,000 population among those aged ≥65 years. Alcohol and drug use disorders were the second most common diagnoses and also decreased with age. In contrast to rates for primary diagnoses, discharges rates among patients with mental illness listed as any of the diagnoses increased with age, ranging from 231.4 discharged patients per 10,000 population among those aged 18–44 years to 650.8 per 10,000 population among those aged>65 years (Table 20). As with primary diagnoses of mental illness, mood disorders were the most common diagnosis, followed by alcohol and drug use disorders.

NNHS

The prevalence of nursing home residents with a primary diagnosis of mental illness in 2004 increased with age, ranging from 18.7% among those aged 65–74 years to 23.5% among those aged ≥85 years (Table 21). Dementia and Alzheimer disease were the most common primary diagnoses among nursing home residents with a primary diagnosis of mental illness, and the prevalence of each increased with age. Among nursing home residents with any diagnosis of mental illness (among any of 16 current diagnoses), mood disorders and dementia were the most common diagnoses among residents aged 65–74 years and 75–84 years (Table 22). Among residents aged ≥85 years, dementia (41.0%) was the most common mental illness, followed by mood disorders (35.3%). In 2004, approximately two thirds of nursing home residents had a diagnosis of a mental illness, and approximately one third of these had a mood disorder.

Discussion

CDC national surveillance surveys such as NHANES and NHIS are important for developing national policies and tracking progress toward national health goals such as those described in Healthy People 2010 and Healthy People 2020. Data from these surveys are useful for national planning and research.

Two state-based CDC surveys, BRFSS and PRAMS, can provide data at the state or substate levels that can be used for both national and state-level planning. For example, variations in BRFSS estimates for certain mental illnesses might help determine the focus of certain mental health services.

The prevalence of current depression varies substantially by state (from 4.3% in North Dakota to 13.7% in Mississippi and West Virginia), as does the prevalence of serious psychological distress (from 1.9% in Utah to 9.4% in Tennessee). These variations might reflect regional differences, including demographic characteristics, socioeconomic conditions, availability of and access to health-care services, and patterns of reimbursement for mental health services, that would be useful in planning (52,53). Southeastern states generally have the highest prevalence of depression, serious psychological distress, and mean number of mentally unhealthy days. This finding likely reflects, in part, sociodemographics, access to and use of health care, and the association between mental illness and certain chronic diseases such as obesity, diabetes, and cardiovascular disease (13,14). For some states, BRFSS, PRAMS, and other state-based surveys have provided mental illness data that state and local authorities have used to identify the need for services at the local or regional level.

CDC surveys focus on depression, and they lack sufficient data on anxiety disorders. Anxiety disorders are as common in the population as depression and, like depression and severe psychological distress, can result in high levels of impairment. Moreover, the pathophysiologic characteristics of anxiety disorders are similar to those of depression and often are associated with the same chronic medical conditions (54–56). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), conducted by the National Institute on Alcohol Abuse and Alcoholism, estimated that during 2001–2002, 14% of U.S. adults had an anxiety disorder (7%, specific phobia; 3%, social phobia; 2%, generalized anxiety disorder; and 1%, panic disorder) (23). Estimates from the 2003 National Comorbidity Survey Replication (NCS-R) were similar, indicating that 18% of adults had an anxiety disorder (9%, specific phobia; 7%, social phobia; 4%, posttraumatic stress disorder; and 3%, panic disorder); 56% of the disorders identified were categorized as serious or moderate (5). Several standardized and validated scales can be used in telephone and in-person interviews to identify and classify anxiety disorders (57,58). Better documentation of the impact of anxiety disorders might help guide national public health policy. At the state and local levels, documenting the prevalence and impact of anxiety disorders might help ascertain the need for additional public health services for these disorders.

Although CDC surveys and information systems have provided important information on the prevalence of mental illness, none of them was designed solely to monitor mental illness. They are general surveillance tools that have added components on mental illness gradually over time as recognition of the importance of mental illness in public health has increased. For example, NHANES and NHIS are national CDC surveys designed to monitor the entire range of public health diseases and conditions and can include only a limited number of questions concerning mental illness. Likewise, the state-based CDC BRFSS is designed to provide state and local estimates on a wide range of health behaviors. BRFSS mental illness questions are primarily contained in two small mental illness modules that are optional for states and are not included on the core BRFSS questionnaire administered by all states. States may choose to administer the optional modules, but not all states do so because of financial constraints, competing state surveillance priorities, and limitations in the length of time respondents are willing to spend completing a telephone survey. The willingness of the states to administer optional modules is affected by the rapid rise in the proportion of households that no longer contain a landline telephone (59). Survey calls to cell phone numbers are limited to BRFSS core questions and do not include the optional survey modules, partly because cell phone respondents are not willing to spend as much time completing BRFSS questions as respondents using landline telephones. Recognizing that the number of households with landline telephones will continue to decrease, CDC is exploring additional methods to obtain a valid sample for mental illness questions in BRFSS.

Increasingly, physicians and others who treat mental illness, as well as public health experts, are recognizing the substantial overlap between mental illness and diseases traditionally considered to be matters of public health concern. The ability of certain mental illnesses to exacerbate morbidity from several chronic diseases is well-established. Recent studies have explored the causal pathways from mental illness to certain chronic diseases (60,61), highlighting the need for more accurate and timely information on the epidemiology of mental illness in the United States. Future mental illness surveillance surveys should measure both depression and anxiety disorders and include more detailed questions concerning their impact on quality of life, associated chronic medical conditions, and issues such as family violence, alcohol and substance abuse, and access to and use of health care. For example, CDC is collaborating with SAMHSA and the Gulf Coast states to conduct surveillance of mental illness in coastal regions affected by the 2010 Deepwater Horizon oil spill. This targeted surveillance effort uses standardized questionnaires to identify the occurrence of anxiety disorders, depression, and psychological distress, as well as the effects of mental illness on and use of mental illness services by the Gulf Coast population.

Increased awareness of the value of mental illness surveillance is important, as is identification of gaps in the available CDC data and data from other sources. The impact of psychological distress and depression is well-documented, and the risk factors and associated issues such as access to and use of health services have been identified. Therefore, increased emphasis should be placed on using this information to initiate public health action and on using surveillance to measure outcomes.

Acknowledgments

This report is based, in part, on contributions by Shilpa Bengeri, Nova Research Company, Hyattsville, Maryland; Janet R. Cummings, PhD, Emory University Rollins School of Public Health, Atlanta, Georgia; Joseph Gfroerer, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland; Elsie Freeman, MD, Maine Department of Health and Human Services, Augusta, Maine; Catherine Simile, PhD, Patricia Barnes, MA, Vladislav Beresovsky, PhD, Yelena Gorina, MPH, MS, Xiang Liu, MS, Susan M. Schappert, MA, Betzaida Tejada-Vera, Anita Bercovitz, PhD, and Jennifer H. Madans, PhD, National Center for Health Statistics, Rosemarie Kobau, MPH, MAPP, Matthew M. Zack, MD, Sherry Farr, PhD, John P. Barile, and Janet B. Croft, PhD, National Center for Chronic Disease Prevention and Health Promotion, Ruth Perou, PhD, National Center for Birth Defects and Developmental Disabilities, James W. Buehler, MD, and JM (Sally) Lin, PhD, Public Health Surveillance Program Office, Hao Tian, PhD, National Center for Emerging and Zoonotic Infectious Diseases, Ileana Arias, PhD, Office of the Director, and Stephen B. Thacker, MD, Office of Surveillance, Epidemiology, and Laboratory Services, CDC.

§ Additional information available at http://apps.nccd.cdc.gov/brfss-smart/index.asp.

** Additional information available at http://apps.nccd.cdc.gov/gisbrfss/default.aspx.

†† Additional information available at http://www.cdc.gov/brfss/technical_infodata/surveydata.htm.

§§ Additional information available at http://www.cdc.gov/brfss/smart/technical_infodata.htm.

¶¶ Additional information available at http://www.cdc.gov/brfss/maps/gis_data.htm.

*** Additional information available at http://www.cdc.gov/nchs/nhis.htm.

††† Additional information available at http://www.cdc.gov/rdc.

§§§ Demographic, questionnaire, examination, and laboratory data sets are available at http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm.

¶¶¶ Additional information available at http://www.cdc.gov/prams.

**** Additional information available at http://www.cdc.gov/prams/CPONDER.htm.

†††† Additional information available at http://www.cdc.gov/nchs/ahcd.htm.

§§§§ Additional information available at http://www.cdc.gov/nchs/nhds.htm.

¶¶¶¶ Additional information available at http://www.cdc.gov/nchs/nnhs.htm.

References
1. US Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. Available at http://www.surgeongeneral.gov/library/mentalhealth/home.html. Accessed July 1, 2011.
2. World Health Organization. Promoting mental health: concepts, emerging evidence, practice (summary report). Geneva, Switzerland: World Health Organization; 2004. Available at http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf. Accessed July 1, 2011.
3. , , , , , . Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych2005;62:593–602. http://dx.doi.org/10.1001/archpsyc.62.6.593
4. , , , . Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych2005;62:617–709. http://dx.doi.org/10.1001/archpsyc.62.6.617
5. , , , et al. The prevalence and correlates of serious mental illness (SMI) in the National Comorbidity Survey Replication (NCS-R) [Chapter 15]. In , , eds. Mental health, United States, 2004. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006. DHHS Pub no. (SMA)-06-4195.
6. , . Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chron Dis2006;3:A42.
7. , Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine2006;3:e442. http://dx.doi.org/10.1371/journal.pmed.0030442
8. , . Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet1997; 349:1436–42. http://dx.doi.org/10.1016/S0140-6736%2896%2907495-8
9. , , , et al. The 12-month prevalence and correlates of serious mental illness, In , , eds. Mental health, United States, 1996. Washington, DC: US Government Printing Office; 1996. DHHS publication no. (SMA) 96–3098.
10. . Assessing the economic costs of serious mental illness. Am J Psych2008;165:663–5. http://dx.doi.org/10.1176/appi.ajp.2008.08030366
11. , , , , . Mental health treatment expenditure trends, 1986–2003. Psychiatr Serv2007;58:1041–8. http://dx.doi.org/10.1176/appi.ps.58.8.1041
12. , , , , , . Individual and societal effects of mental disorders on earnings in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry2008;165:703–11. http://dx.doi.org/10.1176/appi.ajp.2008.08010126
13. , , . The vital link between chronic disease and depressive disorders. Prev Chronic Dis2005;2:A14.
14. , , , , , . Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry2005;58:175–89. http://dx.doi.org/10.1016/j.biopsych.2005.05.001
15. , , . Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosom Med2010;72:641–7. http://dx.doi.org/10.1097/PSY.0b013e3181e10c7b
16. , , , , , . Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation2008;118:1768–75. http://dx.doi.org/10.1161/CIRCULATIONAHA.108.190769
17. , , , . Applying the Institute of Medicine quality chasm framework to improving health care for mental and substance use conditions. Psychiatr Clin North Am2008;31:43–56. http://dx.doi.org/10.1016/j.psc.2007.11.002
18. , ., Sanders D, Vanderpyl J. Unmet needs and treatment seeking in high users of mental health services: role of illness perceptions. Aust N Z J Psychiatry2008;42:147–53. http://dx.doi.org/10.1080/00048670701787503
19. , , . Chronic physical conditions and use of health services among persons with mental disorders: results from the Israel National Health Survey. Gen Hosp Psychiatry2008;30:226–32. http://dx.doi.org/10.1016/j.genhosppsych.2008.02.007
20. , , . Co-occurring mental illness and health care utilization and expenditures in adults with obesity and chronic physical illness. Disease Management2008;11:153–60. http://dx.doi.org/10.1089/dis.2007.0012
21. , , , , Mental illness as an independent risk factor for unintentional injury and injury recidivism. J Trauma2006;61:1299–304. http://dx.doi.org/10.1097/01.ta.0000240460.35245.1a
22. , , , . Death by homicide, suicide and other unnatural causes in people with mental illness: a population-based study. Lancet2001;358:2110–2. http://dx.doi.org/10.1016/S0140-6736%2801%2907216-6
23. , , , , , . Smoking and mental illness: a population-based prevalence study. JAMA2000;284:2606–10. http://dx.doi.org/10.1001/jama.284.20.2606
24. CDC. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50(No. RR-13).
25. , . Principles and practice of public health surveillance.
2nd ed.
New York, NY: Oxford University Press;2000.
26. CDC. Framework for evaluating public health surveillance systems for early detection of outbreaks. Recommendations from the CDC working group. MMWR2004;53(No. RR-5).
27. , , , , eds. Methods for disaster mental health research. New York, NY: Guilford Press;2006.
28. American Psychiatric Association. Diagnostic and statistical manual for mental disorders.
4th ed.
Washington, DC: American Psychiatric Association;2000.
29. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization; 1992. Available athttp://www.who.int/substance_abuse/terminology/ICD10ClinicalDiagnosis.pdf. Accessed June 4, 2011.
30. , . Proposed revisions to psychiatry's canon unveiled. Science2010;327:770–1. http://dx.doi.org/10.1126/science.327.5967.770-a
31. , , , . Structured Clinical Interview for DSM-IV-TR axis I disorders, Research version. New York, NY: Biometrics Research, New York State Psychiatric Institute;2002.
32. , . The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res2004;13:93–121. http://dx.doi.org/10.1002/mpr.168
33. , , , et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord2004;78:131–40. http://dx.doi.org/10.1016/S0165-0327%2802%2900237-9
34. , , , et al. Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires. Psychol Med2008;38:221–8.
35. , . Mental health scales and psychiatric diagnoses: Responses to GHQ-12, K-10 and CIDI across the lifespan. J Affect Disord2010;121:263–7. http://dx.doi.org/10.1016/j.jad.2009.06.038
36. , , , , , . The PHQ-8 as a measure of current depression in the general population. J Affect Disord2009;114:163–73. http://dx.doi.org/10.1016/j.jad.2008.06.026
37. , , . The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med2001;16:606–13. http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x
38. , , , , . Validation and utility of the Patient Health Questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients. Psychosom Med2001;63:679–86.
39. , , , , . Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med2001;16:606–13. http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x
40. , , . Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA1992;282:1737–44. http://dx.doi.org/10.1001/jama.282.18.1737
41. , , , , . Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics–Gynecology Study. Am J Obstet Gynecol2000;183:759–69. http://dx.doi.org/10.1067/mob.2000.106580
42. , , , . Validity of the brief patient health questionnaire mood scale (PHQ-9) in the general population. Gen Hosp Psychiatry2006;28:71–7. http://dx.doi.org/10.1016/j.genhosppsych.2005.07.003
43. , , , , . Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? J Gen Intern Med2005;20:738–42.
44. , . Interpreting scores on the Kessler psychological distress scale (K10). Aust N Z J Public Health2001;25:494–7. http://dx.doi.org/10.1111/j.1467-842X.2001.tb00310.x
45. , , , , ; RTI International. National Survey on Drug Use and Health: serious psychological distress report. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004 Available at http://www.oas.samhsa.gov/nsduh/2k4MRB/2k4spd.pdf. Accessed July 1, 2011.
46. CDC. Health-related quality of life and activity limitations—eight states, 1995. MMWR1998;47:134–40.
47. , , . A population health framework for setting national and state health goals. JAMA2008;299:2081–3. http://dx.doi.org/10.1001/jama.299.17.2081
48. , , . The Centers for Disease Control and Prevention's healthy days measures—population tracking of perceived physical and mental health over time. Health Qual Life Outcomes2003;2:1:37.
49. , , , . Retest reliability of surveillance questions on health-related quality of life. J Epidemiol Community Health2003;57:339–43. http://dx.doi.org/10.1136/jech.57.5.339
50. , , , . Reliability of health-related quality-of-life indicators in cancer survivors from a population-based sample, 2005, BRFSS. Public Health2009; 123:321–5.
51. , , , . Relationship of health-related quality of life to health care utilization and mortality among older adults. Aging Clin Exp Res2002;14:499–508. http://dx.doi.org/10.1007/BF03327351
52. , , Regional differences in mental health in Great Britain. J Epidemiol Community Health1992;46:608–11. http://dx.doi.org/10.1136/jech.46.6.608
53. , , , , , . Metropolitan and micropolitan statistical area estimates of depression and anxiety using the Patient Health Questionnaire-8 in the 2006 Behavioral Risk Factor Surveillance System. Int J Public Health2009; 54:117–24. http://dx.doi.org/10.1007/s00038-009-8026-4
54. , , , et al. Dimensions of depression and anxiety and the hypothalamo-pituitary-adrenal axis. Biol Psychiatry2010;15:366–73.
55. , , , , . Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women. Circulation2005;111:480–7. http://dx.doi.org/10.1161/01.CIR.0000153813.64165.5D
56. , , , et al. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation1994;89: 1992–7. http://dx.doi.org/10.1161/01.CIR.89.5.1992
57. , , , , . Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med2007;146:317–25. http://dx.doi.org/10.7326/0003-4819-146-5-200703060-00004
58. , , , et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med2006; 166:1092–7. http://dx.doi.org/10.1001/archinte.166.10.1092
59. , , , . The impact of cell phones on public health surveillance. Bull World Health Organ2010;77:799. http://dx.doi.org/10.2471/BLT.10.082669
60. , . A prospective study of posttraumatic stress disorder symptoms and coronary heart disease in women. Health Psychol2009;28:125–30. http://dx.doi.org/10.1037/0278-6133.28.1.125
61. , , . Population levels of psychological stress, herpesvirus reactivation and HIV AIDS Behav2010;14:308–17.

FIGURE 1. Prevalence of current depression* among adults aged ≥18 years, by state quartile — Behavioral Risk Factor Surveillance System, United States, 2006§

FIGURE 2. Prevalence of serious psychological distress* among adults aged ≥18 years, by state quartile — Behavioral Risk Factor Surveillance System, United States, 2007§

FIGURE 3. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by state quartile — Behavioral Risk Factor Surveillance System, United States, 2009

TABLE 1. CDC surveys and surveillance systems that collect data on mental illness among adults

TABLE 2. Prevalence of depression* among adults aged ≥18 years, by sociodemographic characteristics — National Health and Nutrition Examination Survey, United States, 2005–2008

TABLE 3. Prevalence of current depression* among adults aged ≥18 years, by sociodemographic characteristics and year — Behavioral Risk Factor Surveillance System, multiple states, 2006 and 2008

TABLE 4. Prevalence of current depression* among adults aged ≥18 years, by state/area and year — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

TABLE 5. Prevalence of postpartum depressive symptoms, by sociodemographic characteristics and symptoms — Pregnancy Risk Assessment Monitoring System, United States, multiple sites, 2004–2008*

TABLE 6. Prevalence of postpartum depressive symptoms, by state and symptoms — Pregnancy Risk Assessment Monitoring System, 22 states, 2008

TABLE 7. Prevalence of serious psychological distress* among adults aged ≥18 years, by sociodemographic characteristics — National Health Interview Survey, United States, 2009

TABLE 8. Prevalence of serious psychological distress* among adults aged ≥18 years, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2007 and 2009

TABLE 9. Prevalence of serious psychological distress* among adults aged ≥18 years, by state/area — Behavioral Risk Factor Surveillance System, United States, 2007 and 2009

TABLE 10. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2009

TABLE 11. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by state/area — Behavioral Risk Factor Surveillance System, United States, 2009

TABLE 12. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

TABLE 13. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime, by state/area — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

TABLE 14. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

TABLE 15. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by state/area — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

TABLE 16. Percentage of adults aged ≥18 years who ever received a diagnosis of bipolar disorder or schizophrenia,* by sociodemographic characteristics — National Health Interview Survey, United States, 2007

TABLE 17. Annual average number and rate of ambulatory care visits* for mental health disorders among adults aged ≥18 years, by diagnosis and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), United States, 2007–2008

TABLE 18. Annual average number and rate of ambulatory care visits* for mental health disorders among adults aged ≥18 years, by age group, sex, and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), United States, 2007–2008

TABLE 19. Hospital* discharge rates among adults aged ≥18 years with mental illness as primary discharge diagnosis, by age group, diagnosis, and sex — National Hospital Discharge Survey, United States, 2007

TABLE 20. Hospital* discharge rates among adults aged ≥18 years with mental illness among any discharge diagnoses, by age group, diagnosis, and sex — National Hospital Discharge Survey, United States, 2007

TABLE 21. Percentage of nursing home residents aged ≥65 years with primary diagnosis of mental illness, by age group, diagnosis, and sex — National Nursing Home Survey, United States, 2004

TABLE 22. Percentage of nursing home residents aged ≥65 years with any diagnosis of mental illness among all diagnoses, by age group, diagnosis, and sex — National Nursing Home Survey, United States, 2004

U.S. Government Printing Office: 2011-723-011/21079 Region IV ISSN: 1546-0738

National Center for Health Statistics Data Brief No. 76 October 2011: Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report May 28, 2010: Attitudes Toward Mental Illness – 35 States, District of Columbia, and Puerto Rico, 2007
Reported By

R Manderscheid, PhD, National Assoc of County Behavioral Health and Developmental Disability Directors. P Delvecchio, MSW, C Marshall, Center for Mental Health Svcs, Substance Abuse and Mental Health Svcs Admin. RG Palpant, MS, J Bigham, TH Bornemann, EdD, Carter Center Mental Health Program. R Kobau, MPH, MAPP, M Zack, MD, G Langmaid, W Thompson, PhD, D Lubar, MSW, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

This is the first state-specific study of attitudes toward mental illness treatment and empathy toward persons with mental illness. The study sought to assess attitudes related to the course of mental illness (i.e., treatment prognosis and possibility of recovery; and perception of supportive behaviors) that might directly influence seeking treatment or recovery and might reflect stigmatizing attitudes amenable to public health intervention. In the 37 jurisdictions surveyed, most adults believed in the effectiveness of mental illness treatment, but fewer agreed that people are caring and sympathetic toward persons with mental illness. These results have public health implications because adverse attitudes about mental illness can lead to stigmatization of persons with mental illness. In addition, the results have implications for mental health treatment because adults who do not believe in the effectiveness of mental illness treatment might be less likely to seek treatment when needed. Also, persons with mental health symptoms who believe that others are not caring and sympathetic toward persons with mental illness might be less likely to disclose mental health problems to friends, family members, colleagues, or other persons who could help.

Some of the adverse attitudes indicated in this report might be caused by stigma experienced by some respondents (e.g., those with mental health problems who received less support at work or at home or who experienced exclusion from activities) (6). Respondents who perceived adverse attitudes about empathy in other persons also might have had less contact with persons with mental illness, or also might harbor misconceptions about the risks associated with mental illness symptoms (7).

Although the study did not include all 50 states and U.S. territories, state-to-state differences were noted, but no clear regional patterns emerged on the attitudes studied. Differences might have resulted from culture and the social environment (e.g., norms, customs, language, lifestyle, and degree of acculturation), differences in how mental health is portrayed in various media, and differences in awareness of and access to mental health treatment. Geographic variability in attitudes toward mental illness and its causes should be a topic of further study.

Attitudes toward persons with mental illness appear to be improving in the United States. One study determined that in 2006, compared with previous decades since the 1950s, more U.S. adults believed that mental health problems could improve with treatment (8). The large proportion of adults with positive attitudes toward mental illness treatment in the United States (and in the 37 jurisdictions studied for this report) might result from antistigma campaigns, and greater attention, awareness, and understanding of mental health (9).

One result from the analysis presented in this report was the varying attitudes by education level. For example, adults with greater education were more likely to agree strongly that mental health treatment can help persons with mental illness lead normal lives but were less likely to agree strongly that people can be caring and sympathetic to persons with mental illness. In one study, among some professionals, more knowledge and contact with persons with mental illness was associated with more stigmatizing attitudes (10). Another possibility is that these adults might have experienced less supportive behaviors associated with mental illness (i.e., feel stigmatized) and thus were more likely to report negative attitudes compared with other groups.

The findings in this report are subject to at least four limitations. First, BRFSS surveys include only noninstitutionalized adults with telephones. Persons in institutions and in households without telephones are excluded, and this population might include a higher proportion of persons with mental health symptoms. Second, because states commonly use only English- or Spanish-language surveys, persons who speak other primary languages are excluded, which could affect race- and ethnicity-specific results. Third, because these data are not nationally representative, no conclusions can be drawn about the entire U.S. population. Finally, the question on caring and sympathy requires further validation in terms of understanding its association with other mental health attitudinal measures (4).

Persons with mental illness generally are able to live successful, full lives, particularly if they receive proper treatment and support. To reduce the effects of stigma, public health and mental health agencies can implement local activities to reduce negative attitudes about mental illness (3). Because the media can frame public opinion, they can be important partners in this and in promoting accounts of mental illness recovery (2). Public educational resources, such as those available on SAMHSA's “What a difference a friend makes” Internet site,** also can reduce negative attitudes toward mental illness by providing information about mental illness and its treatment, and help persons learn how to reassure, be friends with, and accept persons who seek or receive treatment for mental illness.

Acknowledgments

This report is based, in part, on data contributed by BRFSS state coordinators and state mental health services data infrastructure coordinators.

References
1. , , Health-related stigma: rethinking concepts and interventions. Psychol Health Med 2006;11:277–87. http://dx.doi.org/10.1080/13548500600595053
2. News media portrayal of mental illness: implications for public policy. Am Behav Scientist. 2003;46:1594–1600http://dx.doi.org/10.1177/0002764203254615
3. Substance Abuse and Mental Health Services Administration. Developing a stigma reduction initiative. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2006. Available at http://download.ncadi.samhsa.gov/ken/pdf/sma06-4176/developing_a_stigma_reduction.pdf.
4. , , , , Substance Abuse and Mental Health Services Administration/CDC Mental Illness Stigma Panel Members. Attitudes about mental illness and its treatment: validation of a generic scale for public health surveillance of mental illness associated stigma. Community Ment Health J2010;46:164–76. http://dx.doi.org/10.1007/s10597-009-9191-x
5. , , , et al. Screening for serious mental illness in the general population Arch Gen Psychiatry2003;60:184–9.
6. , . Perceived and measured stigma among workers with serious mental illness. Psych Serv2006;57:288–392. http://dx.doi.org/10.1176/appi.ps.57.3.388
7. , , . Familiarity with mental illness and social distance from people with schizophrenia and major depression: testing a model using data from a representative population survey. Schizophr Res2004;69:175–82. http://dx.doi.org/10.1016/S0920-9964%2803%2900186-5
8. , , , et al. Americans' views of mental health and illness at century's end: continuity and change. Public report on the MacArthur Mental Health Module, 1996 General Social Survey. Bloomington, IN: Indiana Consortium of Mental Health Services Research, Indiana University, and the Joseph P. Mailman School of Public Health, Columbia University; 2000. Available at http://www.indiana.edu/~icmhsr/docs/Americans?%20Views%20of%20Mental%20Health.pdf.
9. US Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
10. , , , , Attitudes towards people with a mental disorder: a survey of the Australian public and health professionals. Aust N Z J Psychiatry1999;33:77–83. http://dx.doi.org/10.1046/j.1440-1614.1999.00513.x

FIGURE. Level of agreement* with the statement that people are caring and sympathetic to persons with mental illness, by state and territory — Behavioral Risk Factor Surveillance System, 2007

Alternate Text: The figure above shows the level of agreement with the statement that people are caring and sympathetic to persons with mental illness, by state and territory from the Behavioral Risk Factor Surveillance System in 2007. Six states (Hawaii, Louisiana, Mississippi, Oklahoma, Nevada, and New Mexico) had the highest percentages, and Puerto Rico, the lowest percentage of agreeing strongly that people are caring and sympathetic to those with mental illness.

* Additional information available at http://www.cdc.gov/brfss.

These questions were modified from the 2002 National Scottish Survey of Public Attitudes to Mental Health, Well Being and Mental Health Problems, included in more recent versions of the survey available at http://www.scotland.gov.uk/publications/2009/09/15120147/10.

§ For each question, approximately 2% of respondents answered “did not know” and approximately 0.3% of respondents refused to answer each question.

The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted. Rates are available at http://ftp.cdc.gov/pub/data/brfss/2007summarydataqualityreport.pdf.