A Healthy Mind for a Healthy Population: The U.S. Health Care System Must Pay More Attention to Providing Quality Care to People with Mental Problems or Substance-Use Conditions

By England, Mary Jane; Page, Ann E. K. | Issues in Science and Technology, Summer 2006 | Go to article overview

A Healthy Mind for a Healthy Population: The U.S. Health Care System Must Pay More Attention to Providing Quality Care to People with Mental Problems or Substance-Use Conditions


England, Mary Jane, Page, Ann E. K., Issues in Science and Technology


Each year, more than 33 million U.S. residents receive health care for mental problems and/or for conditions resulting from the use of alcohol, illegal drugs, or prescription medications. The total comprises approximately 20% of working-age adults, a nearly identical portion of adolescents, and 6% of children. Millions more people need care but for various reasons do not receive treatment. For example, although more than 3 million people aged 12 or older received treatment in 2003 for alcohol or drug use, more than six times that number--9% of this age group--reported abusing or being physiologically dependent on alcohol, illicit drugs, prescription drugs, or a combination of these.

Mental problems and substance-use conditions (M/SU conditions, for the sake of convenience) frequently occur together. They also accompany a wide variety of general medical conditions, such as heart disease, cancer, and diabetes, and thereby increase risk of death. For example, approximately one in five patients hospitalized for a heart attack suffers from major depression, and such patients are roughly three times more likely to die from their heart problems than are patients without depression.

Even among people who receive treatment for their M/SU conditions, many often get care that is contrary to what science has shown to be appropriate. Clinicians' departures from evidence-based practice guidelines have been documented for conditions as varied as attention-deficit hyperactivity disorder, anxiety disorders, conduct disorders in children, depression in adults and children, opioid dependence, use of illicit drugs, comorbid mental and substance-use illnesses, and schizophrenia. These deviations from standards of care can result in significant harm to patients.

Collectively, M/SU conditions rank as the nation's leading cause of combined disability and death among women and the second highest among men. The conditions also impose great costs on the economy through increased workplace absenteeism, "presenteeism" (attending work with symptoms that impair performance), days of disability, and significant work failures and accidents. Among children, the conditions adversely affect educational achievement. In sum, M/SU conditions make large and costly demands on the nation.

Clearly, the United States has failed to recognize the magnitude of M/SU conditions and to deliver adequate health care to people in need. To help remedy matters, the Institute of Medicine in early 2006 issued a report detailing the distinctive features of mental and substance-use health care and offering a comprehensive agenda for improving such care.

The report builds on a previous pioneering IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, issued in 2001, that reviewed the nation's general health care system, chronicled its shortcomings, and called for its fundamental redesign. The new report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, finds that its predecessor's conclusions are equally true for M/SU health care. Overall, the system often is ineffective, untimely, inefficient, inequitable, and not patient-centered. At times, it is even unsafe. As is true of general health care, M/SU health care requires fundamental redesign.

In redesigning the system, the guiding principle must be that mental illnesses, substance-use illnesses, and general illnesses are highly interrelated, especially with respect to chronic illness and injury. Improving care delivery and health outcomes for any one of the three depends on improving care delivery and outcomes for the others. A corollary principle is that health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body.

Redesigning the health care system that tends to people with M/SU conditions will require concerted actions by a host of parties.

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