Study provides a healthy dose of good medicine

Praise: The Satcher report's top editor argues that it offers important insights from the world's leading experts on mental disorders.

January 23, 2000|By HOWARD H. GOLDMAN

THE ATTACK by Richard E. Vats on the rigor of Surgeon General David Satcher's report is long on rhetoric and short on science.

The report reflects the best evidence on the epidemiology of mental disorders from the world's leading experts, who were contributors and reviewers for the document. As underscored by the Surgeon General, the worldwide magnitude of the problem of disability attributable to mental disorder is reflected in a recent study of the global burden of disease conducted by the World Bank, the World Health Organization and the Harvard School of Public Health.

The study found that mental disorders are the second leading cause of disability and premature death. Mental disorders account for 15 percent of the burden of disease from all causes, behind cardiovascular disease and just ahead of cancer.

The figures on the prevalence of mental disorder are not new. They have been considered reliable fact for several decades. Recent updates have produced similar results, increasing confidence in the findings.

The studies cited by the Surgeon General focus on the most severe conditions with very reliable criteria for diagnosis, including measures of the severity of distress and dysfunction. Some people do not meet the criteria, lacking one or two symptoms of a condition.

These individuals, who have what the report refers to as "mental health problems," also experience considerable distress and dysfunction. These conditions are not trivial. For example, even "minor" depression accounts for substantial disability in the workplace.

Certainly, any of us might experience a mental disorder, but not everyone meets criteria for a mental disorder during the course of a year. Not everyone needs to seek help, and those who do seek help need not visit a specialist.

Seeking help need not result in excessive use of services.

When Satcher says one in five Americans has one of a selected list of mental disorders, he is speaking of specific health conditions that impose significant distress and interfere with normal life functions.

Mental disorders are significant disturbances of mental functioning mediated by the brain - real conditions with a physical basis.

Fortunately, recent scientific advances have improved the treatments - both drugs and psychotherapy - and the services for people experiencing mental illness. This is qualified good news, because only a minority of individuals with these conditions seek help, including only half of those with the most severe disorders.

Unfortunately, individuals with mental disorders face barriers preventing them from taking advantage of the opportunities created by the therapeutic advances of recent medical science.

As noted, stigma underlies many of these barriers. Stigma is exacerbated by suggestions that only some conditions are "worthy."

Realistically, resource limitations might require that we make hard choices about how much treatment to provide on a case-by-case basis. Broad barriers, however, on the basis of uninformed judgments about who is "worthy" (of insurance coverage, for example) do not serve the public health. Nor do arbitrary limits on the amount of care.

Such policies also are unfair if they do not apply to all health conditions with a similar range of severity and associated disability. The Surgeon General cites recent studies demonstrating that when corporations or states expand mental health benefits and manage care on a case-by-case basis, they do not see dramatic increases in expenditures.

What the report makes clear is that individuals who suffer from mental disorders can choose from a range of treatments of documented efficacy. They can reduce their distress and return to function, and they can reduce the burden on their families and society -without breaking the bank.

All in all, that seems like "good medicine" to me.

Howard H. Goldman, M.D., Ph.D., is a professor of psychiatry at the University of Maryland School of Medicine and a research associate in the Department of Health Policy and Management at Johns Hopkins University's School of Hygiene and Public Health. He served as the senior editor of the Surgeon General's Report on Mental Health.

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