Adolescent Mental Health in the United States

By Michelle L. Nebergall, M.A.

 

Plan of the chapter

            This chapter begins by defining what is meant by mental health, mental illness, mental disorder, adolescents, and the extent of the problem of mental disorder in the United States today.  Next, a discussion of why a public health approach is necessary to addressing this issue is followed by a listing of the components of a successful adolescent mental health public health campaign, a listing of treatment options, discussion on best treatment practices, and the crucial point of combating stigma around mental illness is emphasized.  The chapter concludes with references for additional information.

 

Mental Health

            The state of "mental health" is difficult to define.  It is more than simply the absence of a diagnosable mental disorder.  It varies from individual to individual, and may fluctuate for individuals over time.  In addition, the ways governments, health care providers, and policy organizations define mental health varies.  In this chapter, I use the U.S. Surgeon General’s definition of mental health as “the state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity,”.[1]  Thus, mental health varies for individuals and societies across time and across geographic space.  Regardless of how it is defined, mental health is seen as an essential component to personal and community well-being, and to the ability to contribute to society.  Mental health is also inseparable from physical health; in fact, they are often intertwined.

 

Mental Illness

Mental illness on the other hand is not simply the opposite of mental health.  Mental health and illness are best thought of as points on a continuum.  Some individuals may be located at one end or the other on the continuum, while the majority of individuals fall somewhere along the middle, and move along this continuum of mental illness and health throughout the life span.  Mental illness is a collective term that refers to all diagnosable mental disorders.  Mental disorders are defined by the U.S. Surgeon General as “health conditions that are characterized by alterations in thinking, mood, or behavior, or a combination of these, and these alterations are related to distress and/or impaired functioning.  These alterations can contribute to patient distress, impaired functioning, or elevated risk of death, pain, disability, or loss of freedom,”.[2]  Mental disorders are different from general mental health problems in the intensity and duration of the symptoms.  Many people do experience mental health problems in their lives, such as bereavement symptoms, and though these are not mental disorders, they may require intervention and treatment.  Though general mental health problems can develop into more serious disorders, they will not be a focus of this chapter.

The causes of mental disorders are not definitively known.  Current research suggests that there is a genetic and biochemical basis for most, if not all, disorders, and that environment can influence this basis in various ways (NIMH)[3].  More research into the etiology (including the biological basis) of these diseases is needed, for both treatment and diagnostic purposes.  Currently, most mental health specialists believe mental health and mental illnesses are the product of a complex interaction of biology and environment (NIMH).

 

Categories of mental disorders

Generally, for the public health official, mental disorders can be categorized in the following way[4]:

Depressive Disorders.  These include minor and major depressive disorder, dysthymic disorder, and bipolar disorder, which adversely affect mood, energy, interest, sleep, appetite, and overall functioning (NIMH).  Depressive disorders are differentiated from every-day sadness and depression by their intensity and extreme, persistent symptoms.  An adolescent with a depressive disorder will have trouble functioning at school, home, and in relationships.  It is estimated that the prevalence of any form of depression among adolescents in the U.S. is over 6% in any six-month period, and almost 5% have a major depressive disorder.[5]

 

Anxiety Disorders.  The most common disorders for adolescents, with prevalence rates as high as 13% in any six-month period in the U.S. (NIMH), this group includes generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, phobias, including social and specific (such as of a specific thing or situation such as spiders or heights), and other disorders, such as separation anxiety and selective mutism. 

 

ADHD.  Attention deficit hyperactivity disorder is currently a very controversial diagnosis.  It is often claimed that ADHD is over-diagnosed and medication is over-prescribed for this disorder.  Yet this remains a severe disorder that many adolescents, around 4% in the U.S. (NIMH), suffer from.  More research is needed to understand ADHD and how it effects adolescents.

 

Eating Disorders.  This includes anorexia nervosa, bulimia nervosa, bulimia, and binge-eating disorder.  While these diseases are most often associated with adolescent girls, it is estimated that 35% of adolescents with binge-eating disorder and 5 to 15% with anorexia nervosa or bulimia nervosa are male.  In addition, eating disorders frequently co-occur with other disorders.

 

Autism and Other Pervasive Developmental Disorders (PDDs).  These include Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder-not Otherwise Specified.  These occur in .2 to .6% of U.S. adolescents (NIMH).

 

Schizophrenia.  Schizophrenia is a chronic, severe, and highly disabling disorder that emerges for both males and females during adolescence, making awareness of this disorder among adolescents and families very important.

            These disorders can vary for individuals in their severity, duration, age of onset, and manifestations of symptoms.  These disorders also range from minor to severe, requiring different levels of treatment, to be discussed below.   For more specific information regarding these disorders, consult the Diagnostic and Statistical Manual, or DSM-IV-TR, regarded in the U.S. as the most authoritative source on mental disorders.[6]

 

Other mental health problems

Suicide.  Suicide is the third leading cause of death for people 15-24 years old in the United States, and 15% of all suicides in 2000 in the U.S. were committed by individuals under the age of 25 (CDC).  This is more than death from cancer, heart disease, AIDS, birth defects, stroke, and chronic lung disease combined (CDC).   Suicide is clearly related to mental health problems, especially depression, and these numbers do not even reflect suicide attempts.  While females are more likely to attempt suicide, males are more likely to die from suicide.  Suicide prevention should be a goal of any mental public health campaign.   

 

Violence.  The role of violence warrants mentioning.  Violence prevention programs are categorized in the U.S. Department of Health and Human Services (USDHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) under the Center for Mental Health Services.  Some research does indicate that youth with a mental illness are at greater risk for being a perpetrator or victim of violence (SAMHSA).  Violent acts have also been associated with individuals suffering from oppositional defiant disorder, conduct disorder, and intermittent explosive disorder (SAMHSA).  However, there is no causal relationship between violence and mental illness, despite a common misperception that the mentally ill are violent (NIMH).  Addressing this stereotype of those with a mental illness as violent is an important component of anti-stigma campaigns.

 

Substance Abuse.  Substance abuse is often related to mental health problems.  Substance abuse can exacerbate an already severe problem, or contribute to the onset of some problems.  For more information on substance abuse and its links to mental health, visit the NIMH website and the chapter in this textbook: Substance Abuse and Public Health Policy.  The not-for-profit organization Bright Futures also offers on its web page, www.brightfutures.org, information regarding how to help individuals with a substance abuse problem.  This web site also includes Bright Futures in Practice: Mental Health (2002) which includes specific strategies that are useful for both families and healthcare providers on how to recognize and intervene on particular mental health problems.

 

Mental Illness and Adolescents

Adolescents are generally defined in the medical literature as somewhere between the ages of 10 and 19, though some researchers will consider those up to age 23 or 24 as adolescents.[7]  Here, adolescents are defined as between the ages of 12 and 24, as many individuals in this age group in the United States have similar mental health needs, barriers, and situations.

In U.S. adolescents, the average prevalence rates of mental disorders ranges from 8 – 22%[8], with anxiety, mood, and conduct disorders being the most prevalent.  In addition, rates of co-morbidity are high (CDC, NIMH).  Disorders that adolescents most commonly develop are anxiety disorders, mood disorders, substance-related disorders, psychotic disorders, adjustment disorders, and eating disorders (DSM-IV-TR).  Some researchers claim that the developmental stage of adolescence itself can be a risk factor for developing certain disorders such as depression, eating disorders, and social phobias because of their increased prevalence in adolescents.[9]

Research indicates that depressive disorders emerging during adolescence persist throughout the entire lifespan, and may be a predictor of serious illness in adulthood (NIMH).  Further, some research suggests that bipolar disorder that develops in childhood or early adolescence as opposed to late adolescence or early adulthood represents a more severe form of the illness (NIMH).  Thus, early diagnosis and treatment is imperative to the healthy development and transition to adulthood for adolescents.

 

Burden of mental illness on the population

Mental illness is the second leading cause of disability in economies such as the United States (Surgeon General).[10]  In the U.S., 15% of all disabilities are mental disorders (Surgeon General).  At any given time in the U.S., developmental, behavioral, and mental disorders affect an estimated 7 to 12 million children and adolescents.[11]  The Surgeon General estimates that this is 21% of U.S. children in this age group,[12] all of whom are experiencing some type of impairment related to their mental disorder, and 11% of which are experiencing significant functional impairment as a result of their disorder (NIMH).

Mental illnesses result in high morbidity for a population.  However, mortality is also an issue, with suicide, alcohol-related deaths and injuries, and car “accidents” (which can be suicide attempts masked by reporting protocols), being a major killer of adolescents in the U.S. (CDC).  In addition, these are chronic illnesses, and thus a public health approach should focus on resiliency, long and short term illness management, examine a combination of drug and therapy care, and emphasize community-based care for these patients.  The Centers for Disease Control (CDC) utilizes the concept of “health-related quality of life” as a tool to measure the ways American individuals and groups perceive their own mental and physical well-being.[13]  Results of these studies reveal that the age group of 18-24 years suffers the most mental health-related to stress as compared to other age groups.[14] 

Despite this large problem and the tremendous disability resulting from it, the majority of adolescents who need mental health treatment do not seek it (Surgeon General).  In any given year, it is estimated that fewer than one in five (20%) of youth in the U.S. who need treatment actually receives it (Surgeon General). Thus, a primary goal of a public health initiative geared towards adolescent mental health is to strongly suggest that those who need help seek it.  Highly efficacious treatments exist if accessed.

 

Why a public health approach is necessary in addressing mental health

Mental health has been named as a public health and international health priority by the U.S. Surgeon General in 1999 and the WHO in 2001.  This move is largely in response to the recognition that mental illness of varying degrees is an overwhelmingly common problem creating considerable burden and disability world-wide.  According to the WHO, more than 25% of the people in the world will experience a mental or behavioral disorder at some point in their lives.[15]  Further, the prevalence of these disorders is rising, or at least the extent of the disability resulting from them is rising (WHO).  The WHO estimates that while in 1990 10% of the totally disability-adjusted life years (DALY’s) lost were due to mental and neurological disorders, the DALY’s lost due to these causes had risen to 12% in 2000 and is projected to reach 15% by 2020 (WHO). 

This means mental health problems, a category which includes self-inflicted injuries, is the third largest cause of lost DALY’s.[16]  Further, these measures are probably underestimates, as many other illnesses resulting in lost DALY’s may have at their root cause a mental health problem (such as liver problems caused by alcoholism, or risky behaviors, spurred on by depression or other mental illness, resulting in acquiring an STD).

In response, the WHO report claims the public health approach is necessary due to the “sheer magnitude of the problem, its multifaceted etiology, widespread stigma and discrimination, and the significant treatment gap that exists around the world,” and emphasized the need for public health education and awareness campaigns aimed at reducing stigma and discrimination.[17]  In addition, the Surgeon General’s report (1999) and the WHO World Health Report (2001) emphasize that the responsibility for the public’s mental health lies with national governments.

The burden and disability from mental disorders in the United States is disproportionately felt by youth and racial and ethnic minorities (Surgeon General).  While the prevalence of mental disorders in these populations is similar to that of the larger population, lower utilization of services and worse quality of care, combined with over-representation of minorities in the country’s vulnerable groups (such as the homeless and those in prison), historical issues of racism and discrimination leading to lower social and economic status, and many other factors result in higher burden and disability for minority groups.[18]  This illustrates the social, political, and economic nature of mental illness.

These reasons support the appropriateness of the public health model for addressing adolescent mental health issues.  Public health models assume a holistic approach to health and illness, including environmental and societal factors central to mental health.  This model also addresses the need for strong support for mental health initiatives, and can implement public education and awareness campaigns aimed at reducing stigma and discrimination.  While there is still much to be learned about mental health and mental illness, the needed resources are currently available to reduce the burden of mental and behavioral disorders globally[19], making the PH initiatives viable.  What is needed now is action.

 

What are the components of a good adolescent mental health public health campaign according to the U.S. Surgeon General?

 

1. Research.  More research is needed to understand the etiology, course, outcome, and treatments of mental illness among adolescents in the United States.  Public health organizations should encourage educational and institutional support for this type of research.  The application of this knowledge should focus on treatment and prevention.

 

2. Combat stigma.  This is crucial to the success of any public health campaign.  There is tremendous stigma attached to individuals who suffer from a mental illness, including viewing the mentally ill as violent, unpredictable, incompetent, unintelligent, and even less than fully human.  Stigmatizing stereotypes such as these are unfounded and incorrect.  This stigma provides many layers of barriers to treatment and recovery: it can prevent an individual from acknowledging their mental health problems to themselves as well as others, and from seeking treatment due to fear of being stigmatized.  Once in treatment, many patients are disempowered as their caregivers view them as incompetent.  Recovery is also hindered by stigma resulting in employment and housing discrimination. 

The media can be a powerful tool in campaigns to reduce the stigma attached to mental illness.  In addition, researchers in the United Kingdom have created a database with a flexible power point presentation that psychiatrists can access and use to combat stigma.[20]  (more below, under The Role of Stigma).

 

3. Public outreach to bring those in need of services in for screening.  Through the use of public education and outreach campaigns, raising public awareness of disorders and the efficacy of treatment and medication to treat a diagnosed disorder is essential. 

 

4.  Improved access to care.  Access to services is particularly difficult for teens for a variety of reasons: stigma, finances, transportation, etc.  These barriers need to be addressed, making the most non-invasive and efficacious easily accessible to youth who need them.

 

5. Improve mental health screening.  This will facilitate entry into treatment.  This can be done by screening youth in primary health care settings, at school, in the child welfare system, and in the juvenile justice system.[21]

 

6.  Referrals.  Once a diagnosis is made, adolescents need to be referred to the proper services.  Referrals should continue to be made if treatment is not successful for an individual, and as individual’s needs change.

 

7.  Increase number of adolescent specialists.  There is a shortage of mental health care providers trained to work with youth and a lack of services that are youth-centered.  There is also a shortage in treatment experts in cognitive behavioral therapy and interpersonal therapy, two very effective methods of treatment for treatment.  Universities and governments can create incentive programs to facilitate the entry of more qualified individuals into these fields. Public health organizations and governments can advocate for university and institutional support for the education of adolescent and child mental health specialists. 

 

8.  Care should be informed by best-practices research.  A combination of medication and therapy is often the most successful strategy for care.  Mental illnesses are chronic conditions, and severity and health care needs vary over time for an individual.  Treatment should thus involve the careful monitoring of patients to ensure that when needs change, the treatment responds.  This is particularly important for adolescents who are undergoing rapid physical, emotional, and psychological change.   

 

9. Comprehensive approach.  Mental health services should embrace a comprehensive approach to treatment as this has shown to be highly efficacious.  In addition, mental illnesses, and related problems such as suicide, are complex problems, necessitating a comprehensive approach.[22]  This includes community based services, well-trained service providers and continuity of care provision, family support services, and services sensitive to cultural issues (including language translation).  A comprehensive approach also includes strategies such as providing adolescents with educational services, sex education and family planning, healthcare services, recreational activities such as sports, and services around their mental health care such as transportation to and from appointments. 

 

10. Eliminate disparities in care.  Racial and ethnic disparities in health care impact adolescents as well as adults.  State–of–the–art treatments and supportive, non-discriminatory care should be available to all adolescents.

 

11. Insurance parity.  Lack of parity between insurance coverage for mental health services and other health care services presents a tremendous financial barrier to an adolescent’s ability to access needed services.  One place to begin is with Medicaid, the largest insurer of adolescents in the United States, though coverage of mental health and substance abuse services for adolescents under Medicaid varies state by state.  Many states do not cover long-term care that is essential for the management of mental illnesses.  Private insurance often offers inadequate coverage as well. 

The 1996 Mental Health Parity Act does require health insurance plans to offer the same benefits for mental health as they do for physical health.  This law was signed into law on September 26, 1997 and took effect on January 1, 1998.  In addition, the Clinton administration ordered the Office of Personnel Management to achieve parity for mental health services (as well as substance abuse services) for federal employees (in the Federal Employees Health Benefits Program) by the year 2001.[23]  One argument against parity for these types of services is fear of high cost to third party payers, and a rise in insurance premiums.  See the chapter in this on-line textbook: Parity for Mental Health: History and Consequences for more on this.

 

Treatment Options

The days of mental institutions have passed, and except in extreme cases requiring hospitalization, outpatient and community based care supervised by a therapist are the norm in the United States.  Most patients will be treated with a combination of therapy, medication, and support programs, the specifics of which are tied to individual needs.  The two most important factors in choosing a mental health therapist is the competence of the provider, and the patient’s comfort level.[24]  There are four major types of mental health care providers to choose from:

1. Psychiatrists.  Psychiatrists are doctors whose training includes medical school, general medical residency training, and three years of psychiatry residency, plus they are often nationally certified.  Psychiatrists can provide individual, group, and family therapy, psychotherapy, and prescribe medication to patients.

2. Psychologists.  Psychologists are specialists who study the mind and its processes.  Their training is academic, resulting in either a doctorate of philosophy (PhD), or a doctorate of psychology (Psy.D).  In some states, those with a Master’s Degree can also provide services to patients when supervised by a Doctorate.  Psychologists can evaluate, assess, test, and treat mental disorders.  There are also types of psychologists, with clinical, school and counseling psychologists being the most common.

3. Social workers.  Social workers are must be trained in clinical psychology and be certified by their state to offer services in mental health.  Social workers, under the supervision of a psychiatrist or a psychologist, can act as case workers,, coordinate supplementary treatment services such as job placement, and work with other mental health professional in managing a patient’s care.

4. Psychiatric nurses.  Psychiatric nurses are registered nurses (R.N.’s) and can hold either a bachelor’s degree, a master’s, or a doctoral degree, and their level of training determines the level of services they are able to provide.  Psychiatric nurses work under the supervision of psychiatrists or psychologists, and can conduct assessments, psychotherapy, and medication management.

            The type of professional you seek in treating your mental illness will depend on your needs as a patient. 

Medication, in combination with close monitoring and therapy, is a common and effective method of treatment, and is part of a basic comprehensive treatment plan for adolescents.  The safety and efficacy of prescribing medication to adolescents is a concern for the health care system.  To date, research, such as clinical trials, on medications that treat mental disorders, have only been conducted with adults.  More studies need to be conducted into the ways specific medications affect adolescents.  Currently, the American Academy of Child and Adolescent Psychiatry (AACAP) advises that physicians prescribing medication to teens should fully explain the reasons for using medication to the teen and his/her family, as well as the benefits and risks to medication, the proper way to take and monitor the use of medication, and provide the teen and his/her family with treatment alternatives.

A general framework for treatment is as follows:  Primary Prevention.  This includes improved screening, counseling youth at risk for mental disorders and providing support services for youth that aid in the maintenance of mental health, such as employment, etc.  Secondary Prevention.  This incorporates all the treatments listed above, and includes support services that allow those with treatment to live full, productive lives.  Tertiary Care.  This includes follow-up treatments for patients as well as providing housing or hospitalization for the most severe cases.

 

Best practices

Information regarding best practices at all levels of adolescent mental health care are available to professionals.  Members of the AACAP can access the Journal of the AACAP which provides this information.[25]  Pennsylvania’s Department of Public Welfare, Office of Mental Health and Substance Abuse Services provides an excellent guide to best practices http://www.dpw.state.pa.us/Omhsas/Guidelines/Ch_Ad_TOC.asp.  This should only be viewed as one example however.  Other web-based resources are also available, [26] though the latest academic journals should be viewed as the most reliable and up to date source of this information.

 

Juvenile Justice System

            The juvenile justice system is an institution in the United States with a tremendous need for mental health services.  Some studies have shown that 73% of youth in correctional facilities report a mental disorder during screening, and that up to 67% of youth in the juvenile justice system have a substance abuse problem. [27] Girls in the system have slightly higher prevalence rates for mental disorders than boys in the system, with nearly 75% of girls with at least one psychiatric disorder as compared to nearly 66% for boys (NIMH).  More than 40% of youth in the juvenile detention system have disruptive behavior disorders such as oppositional defiant disorder and conduct disorder, either co-morbid with other disorders or as a single diagnosis (NIMH).  The next most common disorders are depression and dysthymia, with prevalence rates of 26.3% for females and 17.2% for males (NIMH). 

With over 106,000 adolescents currently in the U.S. juvenile justice facilities, and even more in the larger juvenile justice system, this is a huge population with disproportionately high rates of mental disorders in need of screening and treatment services.  Yet the system is currently not equipped to handle this problem.  This is a particular point of concern to public health officials, and the juvenile justice system should be focused on as a potential opportunity for connecting with adolescents and for bringing those who need treatment in contact with the proper services. 

 

Medical management issues

There are many economic considerations in these initiatives.  For example, inpatient vs. outpatient care, and follow-up treatments can be costly.  But by instituting all these changes suggested above, the health care system can reduce costs through prevention and patient illness management.  In addition, when good preventive and community-based care is available, in-patient care, which is extremely costly, will only be necessary for the most severe cases.

 

The role of stigma

Stigma is a major obstacle to addressing mental health problems.  Stigma may explain the tremendous disparity in research funding for mental health compared to physical health, despite their inseparability and mental health’s comparably significant burden on the population (US Surgeon General).  While 12% of the global burden of disease is accounted for by mental and behavioral disorders, only less than 1% of many national health expenditures are dedicated to these disorders.[28]  For example, in the U.S., 10-15 million people are diagnosed with breast cancer annually, and about 40,000 women die annually from it (US Surgeon General).  In comparison, 80 million people in the U.S. have a mental illness, almost 15 million of these people have a serious mental illness, and suicide claims 30,000 lives annually (US Surgeon General).  Yet while breast cancer research received $400 million in 1998 from the federal government, that same year suicide received only $40 million (US Surgeon General).

As it has been shown that treatment has significant rates of success for most mental disorders, this extremely high rate of disability from mental disorders could easily be reduced, given the economic commitment by national governments to mental health treatment and prevention.  This point is crucial when we consider the fact that the majority of people with diagnosable disorders are not receiving treatment.

One aspect of combating the stigma against mental health in research is emphasizing the inseparability of mental and physical health, and the synergistic effects they have on each other.  “Mental health is fundamental to overall health and productivity,”.[29]  Further, most illnesses, whether categorized as physical or mental, are influenced by the combination of biological, social, and psychological factors.[30]  A deeper understanding of mental and behavioral disorders has up to this point been hindered by the false separation of mind and body.[31]  Currently, scholars are attempting to break down this false dichotomy.

 

References

The Centers for Disease Control Mental Health Work Group has created a resources page listing mental health organizations and agencies in every state.  This resource page can be accessed at http://www.cdc.gov/mentalhealth/state_orgs.htm.

 

Additional Resources

The AACAP has a user-friendly web page with information on specific mental health issues designed for families to use.[32]   Other excellent internet resources can be found at:  National Institute of Mental Health (www.nimh.nih.gov), Substance Abuse and Mental Health Services Administration (www.samhsa.gov), American Psychiatric Association (www.psych.org), Guide to Community Preventive Services (www.thecommunityguide.org/mental/default.htm), and Guide to Clinical Preventive Services: http://hstat.nlm.nih.gov/hq/Hquest/db/local.gcps.cps/screen/TocDisplay/da/1/s/44975/action/Toc;jsessionid=8230C58E8860FCD5321257ABF974C5AB

The APA provides a list of books on a range of topics relating to mental health and illness that will be of interest to health professionals.  This listing can be found at http://www.apa.org/books.

In addition to the DSM-IV-TR, a number of texts that are excellent resources for public health practitioners exist.  Some of these are:  Child and Adolescent Psychiatry: A Comprehensive Textbook 3rd edition by Melvin Lewis (Editor) 2002, published by Lippincott Williams and Wilkins Publishers, Hagerstown, Maryland; Practical Child and Adolescent Psychopharmacology by Stan Kutcher (Editor) 2002, published by Cambridge University Press in Cambridge, Mass.;  The Handbook of Child and Adolescent Systems of Care: The New Community Psychiatry by Andres J. Pumariega (Editor), Nancy C. Winters (Editor) 2003, published by Jossey-Bass in Indianapolis, IN. 

 



[1] The Surgeon General’s Report: Mental Health: A Report of the Surgeon General.  1999.  DHHS.  Available on-line at http://www.surgeongeneral.gov/library/mentalhealth.

[2] The Surgeon General’s Report: Mental Health: A Report of the Surgeon General.  1999.  DHHS.  Available on-line at http://www.surgeongeneral.gov/library/mentalhealth.

[3] National Institutes of Mental Health (NIMH).  2002.  http://www.nimh.nih.gov

[4] These categories are adapted from the NIMH.  http://www.nimh.nih.gov

[5] Weist, Mark; Golda Ginsburg and Micheal Shafer.  1999.  Progress In Adolescent Mental Health.  Adolescent Medicine: State of the Art Reviews vol. 10, No. 1.

[6] Written by the Task Force on DSM-IV of the American Psychiatric Association.  2000.  Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revised.  APA:Washington, DC. The most commonly used psychiatric classificatory model in the United States is the DSM-IV-TR.  While other models exist, such as the ICD-10 (Icd-10: The Icd-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines.  1992.  Geneva: World Health Organization (WHO), I will base this chapter off the DSM-IV-TR because of the focus on the United States.  In addition to diagnostic information, the DSM-IV-TR includes information regarding the causes of disorders, gender, age at disorder onset, and prognosis statistics, and some research on treatments.

[7] U.S. Centers for Disease Control (CDC), National Institutes on Mental Health (NIMH), American Academy of Child and Adolescent Psychiatry (AACAP).

[8] These varying prevalence rates are the result of methodological differences between research studies.

[9] Weist, Mark; Golda Ginsburg and Micheal Shafer.  1999.  Progress In Adolescent Mental Health.  Adolescent Medicine: State of the Art Reviews vol. 10, No. 1.

[10] The Surgeon General’s Report: Mental Health: A Report of the Surgeon General.  1999.  DHHS.  Available on-line at http://www.surgeongeneral.gov/library/mentalhealth.

[11] American Academy of Child and Adolescent Psychiatry.  http://www.aacap.org/about/index.htm

[12] A 1999 NIMH study also found that nearly 21% of United States children and adolescents aged 9 to 17 had a diagnosable mental or addictive disorder that caused at least some impairment.

[13] More on this can be found at the CDC website, www.cdc.gov

[14] http://www.cdc.gov/hrqol/findings.htm

[15] The World Health Report.  2001.  Geneval: World Health Organization.

[16] Desjarlais, Robert; L. Eisenberg, B. Good, A. Kleinman.  1995.  World Mental Health: Problems and Priorities in Low Income Countries.  New York: Oxford University Press. 

[17] The World Health Report.  2001.  Geneva: World Health Organization.  Page 16.

[18] Surgeon General’s Report.  1999.  Page 3.

[19] World Health Report.  2001.  Page 1.

[20] This is available at www.rcpsych.ac.uk

[21] However, diagnosing and recognizing mental illness in adolescents is often difficult to do.  Further, even when adolescents are properly diagnosed, many adolescents fall through the cracks of treatment because of their “in-between status” – not eligible for children’s services, yet not old enough for adult services.  Further, adolescents have different needs than children or adults, requiring specific care geared towards them specifically.  The age cut-off point for Children and Adolescent Mental Health Services (CAMHS) varies in different services and states across the country.  The cut-off point ranges from 14 to 19 years, with few services dealing adequately with the 16-21 age group.  Further, studies show that children who get caught in the public mental health system are underserved and have a much higher dependence on the adult system later in life.  This problem can be avoided if these other components listed are in place.

[22] Overholser, James and Anthony Spirito.  2003.  Evaluating and Treating Adolescent Suicide Attempts. U.S.A.: Elsevier Science.

[23] Information on this is available at www.opm.gov/pressrel/1999/health.htm. 

[24] Mayo Foundation for Medical Education Research.  2003.  Can be found by searching www.google.com/unclesam keywords mental health providers.

[25] Lay persons can access portions of this journal at http://www.aacap.org/clinical.

[26] Examples of the Ohio Department of Mental Health Best Practices and Initiatives can be found at htt://www.mh.state.oh.us/bpexamples.html.

[27] 2002.  Adolescent Substance Abuse: A Public Health Priority.  Physician Leadership on National Drug Policy.  Center for Alcohol and Addiction Studies.  Providence: Brown University.

[28] World Health Report.  2001.  Page 3.

[29] Surgeon General’s Report.  1999.  Page 14.

[30] World Health Report.  2001.  Page 8.

[31] World Health Report.  2001.  Page 10.

[32] This web page can be found at http://www.aacap.org/publications/factsfam/index.htm.