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January 1, 1999
The federal government is in the final stages of deciding on a national health agenda for the first decade of the new millennium. High on the priority list are several goals related to improving mental health and reducing substance abuse.
An extension of the Department of Health and Human Services' Healthy People 2000 initiative, Healthy People 2010 will reflect a heightened focus on the science of prevention; improving surveillance and data systems; and demographic changes, including the aging of the U.S. population.
The goals and priorities that will be included in the Healthy People 2010 agenda are intended to guide both public and private health-related activities and to be used by health policymakers at the local, state, and federal levels.
The components of the 2010 project will reflect two overall goals, according to the HHS Office of Disease Prevention and Health Promotion: "to increase the quality and number of years of healthy life and to eliminate health disparities associated with race, ethnicity, socioeconomic status, gender, age, and disability."
For critical target areas-which are elucidated after input from more than 200 state agencies and 350 national organizations, including APA-the project identifies specific objectives and outcome measures with 10-year targets. HHS staff monitor progress toward those health-promotion and disease-prevention objectives throughout the decade.
With mental health and substance abuse two of the areas with prominent places on the Healthy People 2010 agenda, APA sought and was granted an opportunity to address the project's policymakers on the importance of intensifying the project's attention to the underdiagnosis and under-treatment of mental illness, the stigma patients face, and the inadequate funding devoted to treating these disorders.
Speaking for APA, former APA president Harold Eist, M.D., painted a stark picture of the discriminatory situation those with mental disorders often face. For example, "over the past five years, expenditures for medical and surgical care in America have gone up by 4 percent to 7 percent," he pointed out, "while expenditures for care of those with mental illnesses have gone down over 50 percent." Statistics repeatedly show that "the vast majority of those suffering from mental illnesses get no treatment whatsoever."
Among the most seriously undertreated segments of the population are children, minorities, the elderly, the poor, those with disabilities, substance abusers, homeless persons, and prisoners, Eist said. The urgency of remedying this health care tragedy cannot be overstated, he noted, and will require reallocating resources that are earmarked for less pressing health care needs.
"We can begin to end millions of tragedies in the making if we but open our hearts and minds today and enjoin the administration and Congress to assure adequate and fair care, not just for some, but for all of our people," Eist emphasized in his testimony.
The draft of the Healthy People 2010 agenda lists 24 goals in the mental health section, some with specific targets or outcomes, and others still awaiting numerical targets to be designated.
With suicide the ninth leading cause of death in the U.S., two of the goals, for example, aim to bring about significant reductions in suicide rates. One envisions prevention programs that will lead to a reduction of about 14 percent in the U.S. suicide rate, from 11.2 per 100,000 to no more than 9.6 per 100,000 by 2010. The other addresses youth suicide in particular and plans to achieve a 36 percent reduction in the decade in the prevalence of "injurious suicide attempts" among ninth to 12th graders, from 2.8 percent to 1.8 percent.
The agenda also targets mental disorders among children and adolescents in other areas and will focus specifically on eating disorders, children in foster care, and prevention aimed at reducing "early-life risks."
Other goals and objectives hone in on decreasing the percentage of homeless people who suffer from serious mental illnesses, rehabilitating persons with mental disorders so they can hold jobs, boosting the number of states that have plans to ensure that their mental health delivery systems reflect "cultural competence," and increasing to about 80 percent the proportion of Americans who have insurance for inpatient and outpatient mental health treatment.
With an acknowledgment that "numerous mental health problems that manifest in adolescence and young adulthood have their roots in early childhood," several objectives deal with enhancing primary care providers' ability to diagnose risk factors and psychiatric problems and to deliver mental health care to their patients, particularly children.
One, for example, will increase the proportion of primary care providers trained to screen for these problems in infants, toddlers, preschool, and school-aged children and adolescents. Another would boost the percentage of primary care providers "trained to offer information and make referrals for parent training that focuses on the mental health needs of infants, toddlers, and preschoolers." A third goal is to "increase to at least 75 percent the proportion of providers of primary care for children who include assessment of cognitive, emotional, and parent-child functioning with appropriate counseling, referral, and follow-up in their clinical practice." It is esimated that 55 percent of both pediatricians and nurse practitioners provide these services.
One issue Eist highlighted in his APA testimony was the subject of several additional objectives. Inadequate insurance coverage and the resultant delay or absence of treatment, the draft agenda states, have serious consequences for children and adults and must be remedied. Thus Healthy People 2010 will attempt to increase to 25 percent and 10 percent, respectively, the percentage of full-time workers who have inpatient and outpatient mental health care insurance on a par with that for physical disorders. Data from 1993 place those figures at 13.8 percent for inpatient coverage and just 3.3 percent for outpatient.
The agenda also calls for an unspecified increase in the percentage of children who have coverage for mental disorders treatment, noting that there are no data indicating the percentage of children fortunate enough to have such coverage.
Summarizing the seriousness of the problem, the draft report states, "Unfortunately, the vast majority of individuals needing mental health services do not receive them. Only four out of every 10 with a lifetime history of at least one mental disorder ever obtain professional help for their illnesses; of those, only one in four received treatment in the mental health sector." The situation is even more dire for children and adolescents, it points out, of whom only about one-third ever receive help for their psychiatric problems.
The agenda will also include goals that should lead to improved mental health services for prisoners, the elderly, and those with comorbid mental illness and substance abuse disorders.
In the substance abuse arena, the decade should see the government focus on reducing alcohol- and drug-related automobile and boating accidents, a significant reduction in emergency room visits linked to drug abuse, and a decrease in the number of intentional injuries attributable to alcohol- and drug-related violence.
As with the mental health goals, many of the substance abuse objectives are aimed at children and adolescents. The agenda commits the country to increasing to 59 percent from 46 percent the proportion of high school seniors who report they have never used any illicit drug. The project also plans to work to take on the difficult task of increasing from 18 pecent to 24 percent the proportion of high school seniors who state they have never drunk alcoholic beverages.
Also on the agenda are halting the rise in binge drinking among 18- to 34-year-olds and reducing the number of high school seniors who use inhalants or steroids.
U.S. Surgeon General David Satcher, M.D., stressed that the key to meeting the project's many goals over the decade beginning next year depends on the strength of "public-private partnerships." The Healthy People 2010 agenda is scheduled to be released next January.
The Web address for Healthy People 2010 is web.health.gov/healthypeople/; the Office of Disease Prevention and Health Promotion's Web site is odphp.osophs.dhhs.gov/.