By Anne Federwisch, OTR
Posted Date: January 17, 2000

Mental Health: A Report of the Surgeon General, the latest from the top public health official, doesn’t really say anything new, experts say. But the fact that it exists emphasizes the importance of mental health and could move it up from the back ward in terms of public attitudes, treatment, and funding, mental health advocates contend.

“Mental health has been kind of pushed to the wayside,” said Carol Musil, PhD, RN, a psychiatric nurse and assistant professor of nursing at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. “That’s why this report is really critical.”

Released in December 1999, this is the first surgeon general’s report to deal with mental health. “As a psychiatric nurse, [I think] it’s a dream that the surgeon general did this [report] because it puts it on a par with the 1964 report on smoking,” said Connie Vance, EdD, RN, FAAN, professor and former dean at the College of New Rochelle School of Nursing in New York. Since then, 27 of the other 51 surgeon general’s reports have focused on smoking, eventually changing public policy.

What it says

“The [mental health] report emphasizes the scientific revolution and documents the evidence behind successful treatments,” said Clarke Ross, deputy executive director of public policy for the National Alliance for the Mentally Ill (NAMI), headquartered in Arlington, Va. “But then the report goes on to document that most Americans do not receive the state-of-the-art treatments that we know work.”

The report attributes the gap to a combination of causes. The stigma of mental illness prevents many from seeking treatment. The lack of adequate health insurance for psychiatric problems prevents some, especially those with chronic illnesses, from being able to afford adequate care. And the common practice of what the document calls “the destructive split between ‘mental’ and ‘physical’ health” often leaves patients with fragmented and separate—but not equal—treatment for their psyches.

The statistics the report cites underscore the significance of mental illness in overall health. In developed nations, mental disorders account for 40 percent of the leading causes of disability in people over age 5, with major depression ranking No. 1.

“Probably the thing that’s gotten the most press is that 20 percent of adults have a diagnosable mental disorder at any given time, but only about a third of them are getting treatment,” Musil noted.

Implications for patient care

Despite the dire statistics, the report’s summary of existing research and the positive spin it puts on psychological well-being has mental health advocates hopeful that it will usher in what Surgeon General David Satcher, MD, PhD, calls “a healthy era of mind and body for the nation.”

Yet the challenges are formidable. As the authors note in the foreword, “(D)espite unprecedented knowledge gained in just the past three decades about the brain and human behavior, mental health is often an afterthought and illnesses of the mind remain shrouded in fear and misunderstanding.”

That fear and misunderstanding is all too real for Jane and Tom Reinsel of Fairfax, Va., whose 8-year-old son was diagnosed with childhood-onset bipolar disorder three years ago. Their experience mirrors that of many other families dealing with the stigma of mental illness.

“If he had a physical handicap or cancer, friends would be bringing us casseroles and helping out,” Jane Reinsel said. But instead, many of their acquaintances think Ben’s behavioral problems stem from their being poor parents. “Dealing with the illness itself is hard enough, but dealing with everyone else’s reaction is even more difficult.” Her hope is that the report will become widely known so that people understand that her son is a normal little boy who happens to have a neurological brain disorder, for which he’s getting treatment.

Limitations of the report

Although the media coverage of the surgeon general’s latest paper could do a lot to change society’s attitudes toward psychiatric illnesses, it doesn’t offer any specifics on changing public policies in mental health to improve treatment delivery and efficacy, according to NAMI’s Ross. “The report could have provided a better public service if it had contained more explicit policy proposals,” he said. But he noted that it will be useful to the advocate community as well as the political arena to justify a variety of new proposals.

The report also lacked particulars about allied health contributions in mental health, said Marian Scheinholtz, MS, OTR, a practice associate with the American Occupational Therapy Association. “I was kind of disappointed with what was there about rehabilitation,” she said, though overall she had a favorable impression of the surgeon general’s efforts. “I wish I had seen a little bit more [in the report] because I think there is anecdotal evidence about the impact of occupational therapy, particularly with people with mood disorders.”

Call to action

Scheinholtz and others view the report as a call to action for health professionals—whether they practice in mental health settings or not.

“All nurses should take notice of this,” Musil said. “So many people are underdiagnosed in general practice settings.”

Nurses and other health professionals need to work toward incorporating mental health assessments into overall evaluations of patients, she said. “One of the things nurses can do on the patient level is to participate in these [mental health] assessments as a natural piece of the whole health and wellness picture,” Musil said. Identifying psychiatric needs and making appropriate referrals is a crucial step in getting people the treatment they need. “There’s a lot that nurses can do to foster health in their clients, including fostering mental well-being,” she said.

To do that, educators need to highlight the research compiled in the report and emphasize “the prevalence of mental disorders and the importance of prevention and treatment,” Vance said. Nurses should make sure that funding for nursing research reflects the importance of mental health issues, she said.

If the report spurs public policy changes in treatment and funding for mental health, opportunities could flourish for psychiatric health professionals. But nursing and allied health leaders face an uphill battle to increase the number of clinicians working in mental health, said Sarah Raphel, MS, RN, a clinical specialist in child and adolescent psychiatric care and director of nursing practice for the American Nurses Association. “We’re a dwindling group,” she said. “The stigma related to the illness for the patient is also the same for the professionals working in mental health.”

It’s hard to convince students that psychiatry is a rewarding career path, said Linda Finke, PhD, RN, a child psychiatric nurse and associate dean for graduate programs at Indiana University school of nursing in Indianapolis. “We need a lot more nurses to go into psychiatric nursing,” she said. “We’re actually losing [psychiatric] educational programs across the country because we can’t find enough nurses to go into the positions, even though there are lots of job openings.”

But Musil said that the report reflects the beginning of a new understanding of psychiatric health. “People are beginning to realize that we’ve neglected mental health for a while,” she said. She wants both clinicians and consumers to take away from the report its key messages: “Mental health is integral to overall health.”