mental health

n.

1. A state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life.
2. A branch of medicine that deals with the achievement and maintenance of psychological well-being.
3. A person's overall emotional and psychological condition: Since witnessing the accident, his mental health has been poor.

A positive state of mind engendering a sense of well being that enables a person to function effectively within society. Individuals who have good mental health are well-adjusted to society, are able to relate well to others, and basically feel satisfied with themselves and their role in society.

Breakdown of mental health is a major problem in Western societies: it has been estimated that at least one in four adults will suffer from some form of mental disorder, such as depression, during their life. Many physicians and psychologists believe that individuals are physical, mental, and spiritual beings and that these aspects are interrelated. Consequently, mental health is not possible without both physical and spiritual health.

Although there is no clear cause-and-effect relationship between exercise and mental health, aerobic exercise can improve self-esteem, lessen anxiety, and relieve depression. Exercise can act as a form of meditation, changing the state of consciousness and providing a distraction from stressful situations. Many doctors believe that exercise improves mental health and prescribe exercise to relieve depression and anxiety. Walking is the most frequently prescribed exercise, followed by swimming, bicycling, strength training, and running.

n

A relative state of mind in which a person who is healthy is able to cope with and adjust to the recurrent stresses of everyday living in an acceptable way.

The field of mental health has made many advances, particularly since 1980. These developments include an increased understanding of the brain's function through the study of neuroscience, the development of effective new medications and therapies, and the standardization of diagnostic codes for mental illnesses. However, many questions about mental health remain unanswered, and many people around the world are unable to benefit from the knowledge and treatments that are available.

Seven in ten Americans with a mental illness do not receive treatment. Biases against mental illness and lack of public awareness are among the obstacles that limit access to treatment and affect willingness to seek care. Fewer individuals with major psychiatric illnesses were institutionalized in the United States in the year 2000 than in 1980, but limited community resources had not yet met existing treatment needs. Over one-third of the homeless in the United States have a severe mental illness. The prevalence of dementia is rising as people are living longer, adding to the need for more resources. One of the main challenges for the field of mental health is overcoming the gap between an increasingly sophisticated understanding and treatment of mental illness and the availability of these advances to individuals and populations in need.

Mental, or psychiatric, illnesses are a major public health concern. They adversely affect functioning, economic productivity, the capacity for healthy relationships and families, physical health, and the overall quality of life. They cut across racial, ethnic, and socioeconomic lines to affect a significant proportion of communities worldwide. They tend to develop and manifest in the early adult years, often preventing individuals from leading full and productive lives. The National Comorbidity Survey of 1994 found nearly half of the individuals in its random U.S. sample had a psychiatric disorder over their lifetime, and almost 30 percent had one in the past year. The World Health Organization's World Health Report 1998 lists mood and anxiety disorders among the leading causes of morbidity and mood disorders as the leading cause of severely limited activity. Mental disorders account for a quarter of the world's disability. Comorbidity (having more than one illness) is common and even further increases the risk of disability. Suicide is the eighth leading cause of death in the United States and the third leading cause in the fifteen- to twenty-four-year-old age group. More people die by suicide than homicide.

Dianne Hales and Robert Hales define mental health as

the capacity to think rationally and logically, and to cope with the transitions, stresses, traumas, and losses that occur in all lives, in ways that allow emotional stability and growth. In general, mentally healthy individuals value themselves, perceive reality as it is, accept its limitations and possibilities, respond to its challenges, carry out their responsibilities, establish and maintain close relationships, deal reasonably with others, pursue work that suits their talent and training, and feel a sense of fulfillment that makes the efforts of daily living worthwhile (p. 34).

A healthy pregnancy, adequate parenting, secure attachments to caretakers, regular involvement in groups, and stable intimate relationships all contribute to the development and maintenance of mental health. Mental health does not imply the absence of distress and suffering, or strict societal conformity. Mental health and illness, idiosyncratic beliefs and delusions, sadness and depression, and worry and severe anxiety lie on a continuum. An essential criterion for defining behavioral patterns or symptoms of psychological distress as a mental disorder is that they become significant enough to be functionally disabling and impose substantial increased risks ranging from an important loss of freedom to suffering pain, disability, or death.

Both genetic inheritance and environmental factors influence one's vulnerability to mental illness. Twin and family studies and genetic research have demonstrated the former, though specific genes have been difficult to identify, and there may be multiple genes involved in most psychiatric disorders. Traumatic events throughout one's lifetime, including childhood abuse or neglect, major losses, violence, military combat, and dislocation (as among the urban homeless or wartime refugees) are known to threaten mental stability. Nontraumatic stressors, including unemployment, bereavement, and relational or occupational problems, can impact mental health. Nutritional deficiencies (such as vitamin B12), infections (such as syphilis and HIV [human immunodeficiency virus]), and heavy metal poisoning (such as lead) can all cause psychiatric syndromes. Substance abuse contributes significantly to the exacerbation or even precipitation of other psychiatric illnesses and complicates their treatment. Poverty and home-lessness are risk factors for many of these problems, but may also be the outcome of psychiatric illness and the inability to function independently.

Many models of mental health and illness have been proposed. Emil Kraepelin (1856–1926) contributed to the development of the precise categorization of mental illnesses, particularly in distinguishing the long-term course of psychotic and mood disorders. Sigmund Freud (1856–1939) developed the theory of psychoanalysis, through which he claimed that symptoms of psychiatric disorders, as well as many phenomena of everyday life, have unconscious meanings and sources. Erik Erikson (1902–1994) formulated a theory of human development with specific tasks and crises at different stages of the life cycle. Failure to master these stages can lead to various forms of psychopathology. Neuroscientists have demonstrated molecular models of illness, which involve genetic, developmental, functional, anatomical, and molecular abnormalities of the brain. The biopsychosocial model, proposed by George Engel in the 1970s, integrates the biological, genetic, and molecular mechanisms of illness with a psychological understanding of personality development and response to stress as well as social, cultural, and environmental influences.

The Diagnostic and Statistical Manual of Mental Disorders (its 4th edition, DSM-IV, was published in 1994) is the product of research on standardized diagnostic criteria aimed at creating a common, validated descriptive system for all mental health care providers. It is nearly universally accepted, as it classifies and describes categories of illness and aims to be neutral about controversial theories of etiology (see Table 1). The following descriptions of various mental disorders are based on DSM-IV criteria.

Affective disorders involve a cyclical pattern of significant mood disturbance. A major depressive episode may be precipitated by a stressful life situation but also has genetic factors. Disturbances in appetite, sleep, energy, concentration, and sexual interest are common symptoms. The majority of patients respond to treatment with antidepressant medication and/or psychotherapy. An individual who has long-term (over two years) of minor to moderate depressive symptoms may have

Table 1

Lifetime and 12-month prevalence of DSM-III-R disorders
	Lifetime prevalence (%)			12-month prevalence (%)
Disorders	M	F	Total	M	F	Total
*Includes schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, and atypical psychosis.
SOURCE: Kessler, R.C. et al. (1994). "Lifetime and Twelve–Month Prevalence of DSM–III–R Psychiatric Disorders in the United States: Results from the National Comorbidity Study." Archives of General Psychiatry 51:8–19.
Affective disorders
Major depressive episode	12.7	21.3	17.1	7.7	12.9	10.3
Manic episode	1.6	1.7	1.6	1.4	1.3	1.3
Dysthymia	4.8	8.0	6.4	2.1	3.0	2.5
Any affective disorder	14.7	23.9	19.3	8.5	14.1	11.3
Anxiety disorders
Panic disorder	2.0	5.0	3.5	1.3	3.2	2.3
Agoraphobia without panic disorder	3.5	7.0	5.3	1.7	3.8	2.8
Social phobia	11.1	15.5	13.3	6.6	9.1	7.9
Simple phobia	6.7	15.7	11.3	4.4	13.2	8.8
Generalized anxiety disorder	3.6	6.6	5.1	2.0	4.3	3.1
Any anxiety disorder	19.2	30.5	24.9	11.8	22.6	17.2
Substance use disorders
Alcohol abuse without dependence	12.5	6.4	9.4	3.4	1.6	2.5
Alcohol dependence	20.1	8.2	14.1	10.7	3.7	7.2
Drug abuse without dependence	5.4	3.5	4.4	1.3	0.3	0.8
Drug dependence	9.2	5.9	7.5	3.8	1.9	2.8
Any substance abuse/dependence	35.4	17.9	26.6	16.1	6.6	11.3
Other disorders
Antisocial personality	5.8	1.2	3.5	—	—	—
Nonaffective psychosis*	0.6	0.8	0.7	0.5	0.6	0.5
Any of the disorders above	48.7	47.3	48.0	27.7	31.2	29.5

dysthymia. Substance abuse, medical disorders (such as hypothyroidism), and normal life cycle events in which hormonal changes are prominent (such as the postpartum period) can all cause symptoms of depression and should be considered carefully during an assessment. An adjustment disorder is a milder disturbance of mood that may occur in response to a stressful life situation, such as a personal loss or financial crisis, and that usually resolves when the stress is relieved. About 1 percent of the general population has bipolar disorder, also called manic-depressive disorder, in which manic episodes are present as well as depressive episodes. Mania is characterized by a persistently elevated or irritable mood for at least a week, often with decreased need for sleep, rapid speech, impulsivity in spending and other behaviors, and grandiosity. In more severe manic and depressive episodes, psychotic symptoms may emerge, which can complicate treatment. Bipolar disorder is treated with mood stabilizers, such as lithium or valproic acid, and supportive management. Antidepressant medications alone can precipitate mania in susceptible patients.

Psychotic disorders are characterized by "positive" symptoms such as hallucinations, delusions, and bizarre behaviors, as well as "negative" symptoms such as paucity of speech, poverty of ideas, blunting of affective expression, and functional deterioration. Cognitive problems such as disorganization of thought processes also occur. Schizophrenia is a chronic, disabling illness that affects almost 1 percent of the world population, independent of ethnic or cultural background. Risk factors include a family history and possibly psychosocial stressors. The precise cause is still unknown, but it is clear that certain areas of the brain and certain neurotransmitters are involved. Many of those affected are unable to maintain work or relationships and require supportive services to help them manage basic needs such as shelter and food. Treatment includes antipsychotic medication, comprehensive social services including social and occupational rehabilitation if possible, and substance abuse treatment if necessary. Newer antipsychotic medications such as clozapine, olanzapine, and risperidone have been able to treat more symptoms generally with fewer side effects, allowing many to lead more productive lives. Some patients with schizophrenic-type illness also experience prominent affective symptoms nonconcurrently and may have schizoaffective disorder. These patients often require a mood stabilizer as well as antipsychotic medication. Substance use, especially hallucinogens and stimulants (such as amphetamines and cocaine), can precipitate psychotic symptoms, and these may even endure beyond the period of substance use. Some medical conditions (such as epilepsy and delirium) and some medications (such as steroids) can also cause psychotic symptoms and should be considered in the assessment and treatment of psychosis.

Anxiety disorders are among the most prevalent psychiatric disorders in the general population, and these disorders lead to both psychological distress and increased health care utilization. Panic disorder often manifests with somatic symptoms, such as palpitations, chest pain, nausea, trembling, dizziness, and shortness of breath, and can be easily confused with a medical disorder by both patients and doctors. Patients develop persistent concerns about having further panic attacks. Some develop agoraphobia, or a fear of being in public places where their attacks may be triggered. Other phobias include simple phobia, such as fear of heights or specific animals, and social phobia, which is a marked and persistent fear of certain or all social situations, such as speaking in public or being around others in general. People with obsessive-compulsive disorder have obsessions, characterized by recurrent or persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, and/or compulsions, characterized by repetitive behaviors or mental acts often performed in response to an obsession. After one experiences a traumatic event, in which actual or threatened death or severe injury is witnessed or experienced, one may develop post-traumatic stress disorder. Intrusive recollections of the event (such as nightmares), avoidance of reminders of the event, and increased arousal (such as increased vigilance for potential threats) can all cause significant distress and impairment following a wide range of traumatic events, including an accident, military combat, torture, or rape. Generalized anxiety disorder is characterized by excessive and persistent anxiety or worry about a number of events or activities, such as work or school performance. For all anxiety disorders, specific psychopharmacologic and psychotherapeutic (such as cognitive-behavioral therapy) techniques of treatment can be effective and complementary.

Substance-use disorders are quite common and occur in all segments of society. They can lead to accidents, violent crime, and major problems in school and at work. They can cause or complicate various medical and psychiatric illnesses. Liver failure, ulcers, heart attacks, cognitive disorders, and depression are among the potential outcomes of various substances. These disorders pose major public health concerns for public safety, health costs, economic productivity, and pregnancy risks, among others. Substance abuse is defined as a maladaptive pattern of use indicated by continued use despite persistent or recurrent social, occupational, psychological, or physical problems caused or exacerbated by the use of the substance; or recurrent use in situations that could be physically hazardous (such as driving while intoxicated). With substance dependence, signs of physical dependence such as withdrawal symptoms are often present, and the person spends a great deal of time involved in substance-related activities, uses more of the substance than intended, is unable to cut down, and continues to use the substance despite social, occupational, or physical problems related to it. The first steps of treatment involve developing insight, acknowledging the problem, and wanting to change. There are various self-help groups (such as Alcoholics Anonymous), comprehensive treatment programs, psychosocial interventions, and medications that can help lead to successful recovery for the majority of those with substanceuse disorders.

Childhood disorders include pervasive developmental disorders, such as autism, which occurs in four out of ten thousand people; mental retardation, which can be caused by a variety of genetic abnormalities or prenatal insults; and attention deficit–hyperactivity disorder, which can lead to significant problems in school and in social relationships. Childhood abuse and neglect are tragically quite common, with one million children affected annually in the United States alone. These can have major adverse effects on development of personality, relationships, and the ability to function in the world.

Personality disorders are usually first evident in late adolescence and are characterized by pervasive, persistent maladaptive patterns of behavior that are deeply ingrained and are not attributable to other psychiatric disorders. Biological and genetic factors, as well as developmental difficulties, are significant contributors. Other disorders described in DSM-IV include eating disorders, with restriction (anorexia) and/or binging and purging (bulimia) and impulse control disorders (e.g., kleptomania). Somatoform disorders cause physical symptoms with no apparent medical cause (e.g., hysterical paralysis).

Gender, race, ethnicity, and culture are important factors in determining the expression and risk of mental disorders, and these factors also impact on treatment considerations. Certain disorders are more prevalent in women, such as depression and eating disorders, and some in men, such as substance abuse. Cultural background may influence the idioms of psychological distress. For example, nervios describes for many Latinos a constellation of somatic, anxiety, and depressive symptoms distinct from particular DSM-IV diagnoses. Psychiatric disorders are the main risk factor for suicide, but rates vary significantly depending on gender, age, race, religion, marital status, and culture.

(SEE ALSO: Community Mental Health Centers; Dementia; Depression; Schizophrenia; Stress)

Bibliography

Bromet, E. J. (1998). "Psychiatric Disorders." In Maxcy-Rosenau-Last Public Health and Preventive Medicine, 14th edition, ed. Robert B. Wallace. Stamford, CT: Appleton and Lange.

Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (1994), 4th edition. Washington, DC: American Psychiatric Association.

Eisendrath, S. J., and Lichtmacher, J. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, Jr., S. J. McPhee, and M. A. Papadakis. Stamford, CT: Appleton and Lange.

Engel, G. (1980). "The Clinical Application of the Biopsychosocial Model." American Journal of Psychiatry 137(5):535–544.

Hales, D., and Hales, R. E. (1995). Caring for the Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books.

Jamison, K. R. (1999). Night Falls Fast. New York: Alfred Knopf.

Kaplan, Harold I., and Sadock, Benjamin J., eds. (1995). Comprehensive Textbook of Psychiatry. 6th edition. Philadelphia: Williams and Wilkins.

Kessler, R. C.; McGonagle, K. A.; Zhao, S.; Nelson, C. B.; Hughes, M.; Eshleman, S.; Wittchen, H. U.; and Kendler, K. S. (1994). "Lifetime and Twelve Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Study." Archives of General Psychiatry 51:8–19.

U.S. Public Health Service (1999). The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: Author.

World Health Organization (1998). World Health Report 1998: Life in the Twenty-first Century, A Vision for All. Report of the Director-General. Geneva: Author.

— PAUL J. ROSENFIELD; STUART J. EISENDRATH

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A mental state marked by the absence of personal discomfort and socially disruptive behaviour. Those in good mental health have the capacity to adapt to environmental stresses and they work productively with others or alone. They are usually able and willing to attempt to improve society's condition, as well as their own personal condition.

Answers given nowadays to the question 'What are the characteristics of a mentally healthy person?' are likely to refer to such signs as the capacity to cooperate with others and sustain a close, loving relationship, and the ability to make a sensitive, critical appraisal of oneself and the world about one and to cope with the everyday problems of living. At other times or places, different qualities would have been mentioned, according to the values prevailing in the culture. For the English middle class at the turn of the 19th century, mens sana in corpore sano — a sound mind in a sound body — would have included a disciplined intelligence, a well-stocked memory, qualities of leadership appropriate to the person's station, a respect for morality, and a sense of what life means. There was at that time an absolute refusal, as Clouston (1906) put it, 'to admit the possibility of a healthy mind in an unsound body, or at all events in an unsound brain'. Nowadays we regard mental health as attainable by even the severely crippled. Brain injury may put limits on the degree to which social capacities can be developed, but it does not prevent their development altogether; the influence of the milieu may be as strong as that of the severity of the injury. For a vigorous critique of the concept of mental health one can hardly do better than turn to Barbara Wootton's review (1960) in which, after commenting on a number of proposed definitions, she concluded that 'whichever way, therefore, the problem may be approached, no solid foundation appears to be discoverable on which to establish the propositions [as] formulated'.

The shift in emphasis from intellectual ability to harmonious relationships as the criterion of mental health can be partly attributed to the recognition that, whatever part physical inheritance plays in determining intelligence, intellectual development depends largely on learning in the setting of a relationship. The publication in 1951 by the World Health Organization of John Bowlby's monograph Maternal Care and Mental Health was a landmark because it made it widely known that an essential condition for the mental health and development of the child is 'a warm, intimate, and continuous relationship with his mother in which both find satisfaction and enjoyment'. 'Sound cognitive development', it has been said, 'occurs in a context of communication.' The abilities which enable the child to play the roles appropriate to a boy or girl are acquired through the learning engendered by the expectations of the family. Interruption, or disturbance, during early childhood in the relationship with the mother has been shown to retard or distort the development of language and the skills related to it, and to lead in some circumstances to an impairment in social relationships which lasts into adult life. The effects depend on the character of the 'support' or 'security' system, of which the mother is usually the chief member. The father, the grandparents, older siblings, and family friends contribute to the system. The young child is vulnerable if the system is weak or fragile.

The young child tends to attach himself to one person especially, usually the one who mothers him, and this relationship, established in the second half of the first year of life, prepares him for a monogamous relationship when sexual maturity is reached, and influences then his choice of partner. (See attachment.) Social training of other kinds, in the family and outside it, prepares him for the several roles he is to play in adult life. A boy tends to take his father as a model, and a girl, her mother. Of importance too is membership of a peer group in the early teenage years. From his experience in relationships with his mother and father, peers of the same sex, and then a peer of opposite sex, the young person discovers what sort of person he is — i.e. he forms a conception of himself, or establishes his 'identity', especially his sexual identity. His education and early experience in a job establish his occupational identity. This conception of himself is tested out by further experience which confirms or modifies it. The first affaire confirms or, if it goes badly, confuses his sexual identity. He becomes emancipated in greater or lesser degree from his parents, and free to form relationships outside the family. The rapid intellectual development at the time of puberty helps the young person to understand, and in some degree gain control over, the world around him.

The social training he has had during childhood is put to the test at turning points in circumstances, or 'crises', which require old habits to be abandoned, new habits to be developed. Crises are conveniently divided, following Erikson (1968), into 'developmental' and 'accidental'. By developmental crises are meant those decisive changes in circumstances ordinarily expected to occur in the life cycle — for example, being born, going to school, leaving school, getting married, becoming a parent, or retiring from work. Examples of accidental crises are the untimely loss of a member of the family, a spouse or other loved person, the loss of a job, or illness. If he is prepared for the new circumstances, as is usual when the crisis is developmental, a person acquires new habits quickly through the processes of learning. If not prepared, because the crisis is untimely, or social training has been lacking or inappropriate, a person may go through a period of instability and distress while he works out new ways of coping.

In studies of bereavement — for example, by C. M. Parkes — are to be found illustrations of the differences between mental health and illness. After the loss of a loved one, one person mourns for a time. While doing so, he is able to express to others his grief and distress openly and authentically, and thus to review his relationship with the person lost. He soon re-engages in relationships with others, which change and develop. Another person becomes preoccupied by his fantasies about the person lost. These may be out of keeping with the realities, which are denied. He withdraws from other relationships, and shows a general contraction of activities and interests. He feels diminished and depreciated. Withdrawing from relationships, and unable to communicate his distress, his conception of himself remains uncorrected, and he does not work out a new pattern of relationships. This kind of severe reaction to bereavement occurs especially when the loss has been sudden or unexpected, or there have been distressing circumstances: for instance, if the death was due to suicide, or to the negligence or misconduct of others. Such a reaction may also reflect the personality of the bereaved person and his relationship with the person lost. He may have been unaccustomed to taking decisions for himself, or have had limited personal resources, or have been unduly dependent, or the relationship may have been discordant and fraught with unresolved difficulties.

The features of the reaction of this person are the antithesis of mental health, and amount to mental illness if he also claims exemption from normal social responsibilities. Yet they reflect psychological processes which are part of the organism's normal reactive equipment, and which are adaptive in that they serve to reduce anxiety. They can be described as due to 'the renunciation of functions which give rise to anxiety' (which Sigmund Freud said was the essence of neurosis). The psychological processes are maladaptive in the particular circumstances in that they do nothing to remove the sources of the anxiety. There is thus a deadlock. By avoiding a situation or staying out of relationships in which he has experienced pain or anxiety, a person does not explore and re-evaluate the situation, or learn to cope with it in more effective ways. Other characteristics of behaviour in mental illness are persistence or repetitiveness and resistance to modification by experience, whereas behaviour in mental health tends to be flexible and modifiable.

To break the deadlock, and to restore mental health, a therapist creates conditions in which the testing of reality and learning can be resumed. New habits can then be acquired which are more appropriate to the circumstances. The person's conception of himself can be corrected by further experience. He is encouraged to re-enter into relationships. In other words, the therapist intervenes or mediates in order to bring about reconciliation, and to enable communication with others to be reopened.

(Published 1987)

— Derek Russell Davis

Bibliography
• Clouston, T. C. (1906). The Hygiene of Mind.
• Erikson, E. H. (1968). Identity: Youth and Crisis.
• Goodwin, I. (2003). 'The relevance of attachment theory to the philosophy, organization, and practice of adult mental health care'. Clinical Psychology Review, 23/1.
• Parkes, C. M. (2001). Bereavement (3rd edn.).
• Wootton, B. (1960). Social Science and Social Pathology.

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mental health