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c h a p t e r 2 The Population with Mental Illness Mental illness is far more visible today than it was fifty years ago. People with severe mental illness, once housed in state institutions often located far from population centers, now live in the community. People who were once thought to have personality quirks or to be victims of harsh social circumstances are now described in medical terms as having symptoms of a disorder. Many newspapers now feature stories about mental illness as prominently as stories about cancer. Over this same period there have been radical changes in U.S. society. The divorce rate has tripled. The rate of single parenthood has more than tripled (from about 4% to about 13%). Many more women work in the formal labor market. Men’s jobs have become more unstable. These and many other transformations in society and the economy might have triggered an increase in mental illness. Do the growing awareness and visibility of mental illness or the increased stresses of today’s world mean that its prevalence over the past five decades has been rising? Rising prevalence of mental illness—if true—would confound our analysis of the last half century of changes in the well-being of people with mental illness. If mental illness has grown in prevalence or strikes different groups from those it once did, then these shifting population patterns may be responsible for the historical changes in well-being. What Is Mental Illness? How mental illness is defined over time has been the focus of philosophical debates about the nature of rationality, sociological debates about the meaning of deviance, and legal debates about the definition of criminal responsibility. Advances in social attitudes, scientific understanding, treatment modalities, and diagnostic technology alter the definition of many illnesses over time (Rosenberg, 2002).1 The problems of defining who has an illness and who does not are far more difficult in the case of mental illness than in the case of most somatic illnesses , however, because few mental disorders have biological markers. The Population with Mental Illness 9 Experts continue to spar about the inclusion of specific conditions in each update of the psychiatric diagnosis manual Diagnostic and Statistical Manual of Mental Disorders, the latest of which, published in 2000, is known as DSM-IV-TR (APA, 2000). Even after conditions are identified, epidemiologists argue about how best to measure them in the general population. The balance in these ongoing debates has shifted over time. In earlier eras pitched battles occurred between those favoring more theoretical and personality-oriented categories and those endorsing more medical categories that use a list of signs and symptoms. Recent scientific research has shown how particular mental illnesses cluster in families, how they display similar symptom profiles across diverse cultures and communities , how they follow a predictable course and natural history, and how they respond to treatment (Robins and Guze, 1970; US DHHS, CMHS, 1999). The disabling nature of mental illnesses, especially schizophrenia, major depression, and bipolar disorder, is now abundantly clear (WHO, 2001). Today a medical approach to mental illness is standard. Epidemiologists have used three general sets of constructs (and combinations of these) to define who has a mental illness. One set focuses on symptoms and signs for each particular mental disorder. A second assesses whether a person has mental health-related difficulties in functioning at school, at work, or at home. A third measures whether a person has sought treatment for a mental health condition. The differences among these constructs reflect, in part, the diversity of conditions grouped in the umbrella category of mental illness. Some people are universally acknowledged to be very ill, so impaired in their functioning that state law often requires them to be hospitalized whether or not they want treatment. This small group of severely and persistently mentally ill people accounts for most of the costs of mental health care. A larger group has symptoms that are not as outwardly bizarre or debilitating but that seriously impede their ability to live happy, productive lives. Many with major depression and severe anxiety disorders fall into this category. Others experience an impaired ability to live their lives because of external events, such as the death of a family member. They may benefit from counseling or treatment but often do not meet criteria for a psychiatric diagnosis. Still others have symptoms consistent with a mental disorder...


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