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Chapter Two • The Population with Mental Illness 1. For example, the incidence of breast cancer increased 4 percent per year between 1980 and 1987. Because this was a period of rapid adoption of mammography, the expanding use of new diagnostic technology—rather than changes in underlying health—is considered largely responsible for the dramatic rise in incidence (Garfinkel, Boring, and Heath, 1994). 2. These patterns are true of other conditions as well—many people with medical conditions do not get treatment for their conditions, and many people who seek treatment do not meet the criteria for specific medical conditions. 3. Even these refined estimates are probably flawed in that they are limited by the type of information available in surveys. For example, the effort to adjust the NCS survey estimates incorporated information not only on distress and functioning but also on use of services (Wakefield and Spitzer, 2002). The inclusion of information about use of services makes it difficult to use these refined estimates to assess unmet need for treatment. 4. Each demographic factor is best described as a correlate, not a cause, of a mental illness. Gender, for example, correlates with certain disorders (more women have depression , for example), but gender itself is not the cause. When any demographic factor correlates with an illness, it is usually difficult to infer the direction of causality from the observed correlations. 5. One difficulty in assessing the relationship between race and mental illness is the confounding effect of socioeconomic status. The lower socioeconomic status (SES) of blacks and other minorities might be a greater determinant of mental illness than their race. One early study found, for example, that within both the black and white populations, mental illness increases with decreasing SES (Hollingshead and Redlich, 1958). Today the prevailing view is that the prevalence of mental illness is similar across minority groups; any differences are more likely the result of SES or other factors (US DHHS CMHS, 1999, 2001a). 6. Though education level is not entirely free of this concern—mental illness frequently appears in the late teens and early twenties—it is likely less altered by mental illness than is an individual’s income. n o t e s 7. Dr. Leonard Scheele, then surgeon general of the United States, estimated in 1955 that 725,000 mentally ill patients were hospitalized for their conditions (New York Times, 1955). At the end of 1955 there were 560,000 resident patients in U.S. state and county mental hospitals, according to Grob (1991a, 260). 8. Again, the changes are similar to those for other diseases—the cutoff points for the diagnosis of high cholesterol have changed over time, as have the guidelines for the recommended daily allowance of various nutrients. 9. In 1973, for example, homosexuality was removed as a diagnosable disorder. (Egodystonic homosexuality continues to be listed, a disorder characterized by a pathological response to homosexual identity.) Other behaviors have been added to the list. For instance, with the 1979 publication of DSM-III, social phobia was described for the first time as a discernible type of phobia. Also introduced were somatization disorder (perhaps previously called hysteria or Briquet’s syndrome), post-traumatic stress disorder (supplementing traumatic neuroses), and tobacco dependence. 10. The rate is even lower, 0.04 percent (defined as all psychoses, noninstitutionalized population only), in the 1957 Baltimore study. 11. A similar strategy has been used to project the future need for hospital beds (Goldsmith et al., 1993) and psychiatrists (Koran, 1979; Liptzin, 1979; Pardes, 1979). Kramer (1978, 1983) used similar methods to project the changing prevalence of schizophrenia and severe mental illness in the context of the changing sociodemographic composition of the U.S. population. 12. To the extent possible, we included only factors that are likely to cause (rather than follow) mental illness. We therefore excluded income and instead use individual education as a measure of socioeconomic status. To capture the idea that relative, rather than absolute , education is correlated with mental illness, we measured education in each census year relative to the mean in that year. Other variables included in the regression are gender, minority status, educational attainment, household composition, urbanness, and interactions between age and gender, age and race, race and gender, and race and education. Variables (main effects and interactions) were included if they were statistically significant predictors of symptoms or impairment. Chapter Three • The Evolving Technology of Mental Health Care 1. The technological frontier...


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