Access, Costs and Policy Issues
Rights of the Mentally Disabled
What does it mean to be mentally ill?
What do you envision when you hear the term ‘mentally ill?’ While society’s understanding of the science behind mental health has greatly increased over the last century, it seems that its tendency to stereotype mentally ill individuals has not diminished. Mental Health experts argue that negative media depictions bias children’s perceptions of the mentally ill, leaving them with negative stereotypes that they bring with them into adulthood.
So what does “mental illness” mean? According to the U.S. Surgeon General, “mental illness” is an umbrella term used to describe mental disorders that are diagnosable and characterized by changes in a person’s mood, behavior, or judgment.1
Mental disorders comprise a variety of categories, including anxiety disorders such as phobias and obsessive-compulsive disorders; mood disorders including bipolar disorder and depression; schizophrenia; dementias such as Alzheimer’s disease; and eating disorders such as anorexia nervosa and bulimia.2
For the most part, the causes of mental disorders are not known. Medical researchers posit that avariety of biological determinates, as well as psychological and environmental factors, influence their development. Symptoms for the disorders vary among individuals and may change over time.
To diagnose mental illness psychiatrists, and other mental health professionals, question patients about their symptoms and make observations about their appearance and interaction. They use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to identify disorders based on the specific set of symptoms listed in the manual. The DSM, compiled by experts in the field of psychiatric medicine, provides diagnostic parameters for widely recognized mental disorders, but also sets standards for new illnesses (examples: historic expansion from 66 to over 400 disorders; removing homosexuality from DSM as a mental illness.)
Over the years, this influential diagnostic tool has raised a number of ethical questions. Most recently, a study by researchers in Boston concluded that over half of the mental health experts who helped compile the most recent edition of the DSM had financial ties to companies that make drugs designed to treat mental illnesses.3 The study’s findings ignited a public debate on the ethical implications of scientists receiving monetary support from pharmaceutical companies.
Statistics on the prevalence of mental illnesses are shocking. At any point in time, a whopping 450 million people around the world have a mental disorder.4 A national survey funded by the National Institute of Mental Health found that about one in every four adult Americans (or around 26.2 percent of the entire U.S. adult population) suffers from a diagnosable mental illness in any given year,5 with about one in every 17 U.S. adults suffering from a serious mental illness. The World Health Organization (WHO) estimates that the number of individuals with mental disorders will grow quickly in the coming years. Experts from the WHO predict that increases in stress, poverty, and violent incidents will make mental illnesses the second most common cause of death and disability worldwide by 2020.6
"The Numbers Count: Mental Disorders in America” (National Institute of Mental Health)
"Stigma: Building Awareness and Understanding about Mental Illness” (National Mental Health Association)
Access, Costs and Policy Issues Surrounding Mental Disorders and Mental Health Care
Internationally, access to mental health care is severely limited. WHO has found that over 90 percent of individuals with mental disorders in the developing world do not have access to treatment.7 Inadequacies in care stem from a lack in both governmental funding for and governmental attention to mental health issues. Scarcity of public health funding is a serious problem in much of the world. Many countries do not have the monetary resources to devote to mental health care, and some nations are unwilling to take funding away from other crucial public health initiatives,8 such as HIV/AIDS education programs or projects that seek to reduce child mortality. Governmental policies orientated towards diagnosing and treating mental illnesses are similarly absent. Over the last six years, the World Health Organization has compiled data on global mental health resources in its "Project Atlas" program. The program, which published a report most recently in 2005, has found that around 30 percent of the countries surveyed lack national mental health programs and slightly more than 20 percent lack national legislation specifically relating to mental health.9
Domestically, the U.S. Surgeon General recognized that advances in scientific knowledge regarding mental illnesses were not met by a decrease in the social stigma of mental disorders or mental health care in America, and therefore issued a report in 1999 on the current state of mental health in America and future goals. In 2002, President George W. Bush initiated the New Freedom Commission on Mental Health. The final report of the commission, issued in the summer of 2003, articulated six goals to ensure that all Americans have access to equal and adequate mental health care including early screening, diagnosis, and treatment. Major national legislation on mental health issues in the U.S. includes the Mental Health Parity Act of 1996, which requires insurance companies to cover mental disorders as they would physical disorders. However, the Mental Health Parity Act came under attack in the Senate in May 2006 and to date has not been extended beyond its point of termination on Dec. 31,2006.
The United States lacks a centralized national mental health care policy, and approaches to care vary. The popularity of specific types of treatments for mental disorders has shifted as attitudes towards mental illnesses have changed with time. Since the 1960s, major focus has been placed on community care and recidivism rates.10 Internationally, the popularity of specific treatments also varies.
Click here to learn more about mental health policies and innovative programs in other countries:
India: A Spoonful of Medicine - and a Steady Diet of Normality (Science Magazine)
Zanzibar: A Mental Health Case Study (BBC News)
Iraq: Plans underway for mental health centre in Arbil (IRIN News)
Canada: “Drink Tax Urged to Aid Mentally Ill” (CNews)
Mental disorders are costly both to the individuals who experience them and to the societies that they affect since many are debilitating and long lasting. According to the WHO's Global Burden of Disease study, over 15 percent of the cumulative burden of all diseases in developed countries comes from mental illnesses, which is greater than the collective burden caused by all types of cancers.11 Mental disorders are especially devastating since they can contribute to a sustained loss of income for both the individuals who suffer from them and the family members who are forced to care for disabled relatives. The National Institute of Mental Health estimates that mental disorders are the leading cause of disability in North America for all individuals between the ages of 15 and 44.12
Rights of the Mentally Disabled
Historically, controversy has surrounded the issue of the rights given to individuals with mental disorders at the state, national, and international levels. In some countries, individuals with mental illnesses are denied the right to vote or the right to determine the type of treatment that is administered to them.13 The rights of Americans with mental disorders have improved over the last half century, although they remain hotly debated. In the 1950s, Americans with mental illnesses could be involuntarily confined to mental institutions without the right to treatment or anend to their detention. Currently, individuals with mental illnesses in the U.S. have the right to refuse to take medication, to avoid confinement unless they present a danger to themselves or others, to due process during commitment hearings, and tomedical care. However, many individuals still face discrimination and inadequate treatment based on unfair practices and social stigmatization against individuals with mental disorders.14
The practice of assisted outpatient treatment (AOT), also known as outpatient commitment, for the mentally ill, a treatment plan enacted by court order for individuals who have a history of not taking prescribed medications, is an especially contentious issue. Supporters of such legislation purport that treatment is in the interest of the individual with the disorder and their community since studies have shown that treatment can reduce hospitalization, violence, and arrests. Critics of AOT laws contest this assessment by contending that the practice does not improve treatment compliance and that the coercive nature of the policies violates the civil rights of the mentally ill.15 Forty-two states currently have assisted outpatient treatment laws. The most controversial such law is in New York state, where it is called “Kendra’s Law” in memory of a young woman who died after being pushed in front of a subway train by an individual with a mental disorder who failed to take his prescribed medication and could not get access to the services he needed.16
Crazy: A Father's Search through America's Mental Health Madness by Pete Earley
"New Approaches to Preventing Incarceration of Severely Mentally Ill Adults" (Psychiatric Times)
Stigmas against mentally ill individuals are prevalent throughout the world and usually include misperceptions such as it is shameful to be mentally ill, that people with mental illnesses are violent and dangerous, or that people with mental illnesses cannot live with the rest of society.
Public attitudes towards the mentally ill in America have evolved over time. Through the first half of the 20 th century, Americans had little scientific understanding about what mental illnesses were and viewed mental illness as a condition to be feared. By the mid-1990s, surveys showed that the general public had a more accurate grasp of the scientific understanding behind mental illnesses, but the social stigma towards the illnesses remains today.17 According to the U.S. Surgeon General, people perceive individuals with mental illnesses, especially those with psychoses, as violent and physically dangerousbased in part on media portrayals of the mentally ill and the increased presence of such individuals in their local communities following the trend to deinstitutionalize people with mental disorders over the last half-century.18 Stigmas can cause individuals with mental illnesses to be discriminated against or mistreated and may even contribute to some people with mental disordersto refuse to seek help for their disorders, which prevents them from receiving necessary treatments.
To learn more about the effects of stigma on individuals with mental disorders, click the following links:
"Stigma" an opinion piece on the concept and consequences surrounding stigmas by Michael B. Friedman (Mental Health Association of NYC and Westchester)
Media Madness: Public Images of Mental Illness by Otto Wahl
Sources: “Mental Health: A Report of the Surgeon General,” U.S. Department of Health and Human Services, 1999. “Mental Illness in the Family: Stigma: Building Awareness and Understanding About Mental Illness,” the National Mental Health Association, Revised 2000. “Mental Health,” the World Health Organization. Kessler RC, Chiu WT, Demler O, Walters EE, “Prevalence, Severity, and Comorbidity of Twelve-Month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R),” Archives of General Psychiatry, June 2005. “Surge in Mental Disorders Predicted,” BBC News, January 2001. Greg Miller, “The Unseen: Mental Illness’s Global Toll,” Science, January 2006. “Mental Health Atlas: 2005,” the World Health Organization, 2005. Michelle Chen, “Law to Force Mental Illness Treatment Raises Ire of Civil Libertarians,” the New Standard, April 2005. “Disability Rights,” ACLU Briefing Paper # 21, Winter 1999.
-Kate Amlin, Summer 2006
Special thanks to Michael Friedman, Adjunct Associate Professor of Public and Health Administration at New York University and
Director of The Metropolitan Center for Mental Health Policy Development and Advocacy,
for reviewing this brief.
1) “Mental Health: A Report of the Surgeon General.” U.S. Department of Health and Human Services. “Mental Health: A Report of the Surgeon General.” Washington, DC: National Institute of Mental Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/home.html.
2) “Mental Illness in the Family: Stigma: Building Awareness and Understanding About Mental Illness.” National Mental Health Association. Revised 2000. http://www.nmha.org/infoctr/factsheets/14.cfm.
3) “Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry,” Psychotherapy & Psychometrics, 2006.
4) “Mental Health.” the World Health Organization. http://www.who.int/topics/mental_health/en/.
5) Kessler RC, Chiu WT, Demler O, Walters EE. “Prevalence, Severity, and Comorbidity of Twelve-Month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R).” Archives of General Psychiatry, June 2005.
6) “Surge in Mental Disorders Predicted.” BBC News, January 2001. http://news.bbc.co.uk/2/hi/health/1108793.stm.
7) Miller, Greg. “The Unseen: Mental Illness’s Global Toll.” Science, January 2006.
9) “Mental Health Atlas: 2005,” the World Health Organization, 2005. http://www.who.int/mental_health/evidence/atlas/index.htm.
10) “Mental Health: A Report of the Surgeon General,” and “Mental Health Atlas: 2005.”
11) “The Impact of Mental Illness on Society.” The National Institute of Mental Health, 2001. http://www.nimh.nih.gov/publicat/burden.cfm.
13) Miller, 2006.
14) “Disability Rights.” American Civil Liberties Union Briefing Paper 21, Updated Winter 1999. http://www.aclu.org/disability/gen/10640res20020228.html.
15) Chen, Michelle. “Law to Force Mental Illness Treatment Raises Ire of Civil Libertarians.” The New Standard, 2005. http://newstandardnews.net/content/index.cfm/items/1693.
16) Tammy Seltzer, “RE: Bill 68, an Act to Amend the Mental Health Act and the Mental Health Consent Act, 1996,” testimony before the Standing Committee on General Government of the Legislative Assembly of Ontario, May 15, 2000. Online at http://www.peoplewho.net/readingroom/seltzer.htm.
17) “Mental Health: A Report of the Surgeon General,” 1999.