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I am pleased to issue the first-ever Surgeon General's Report on MentalHealth. In doing so, I am alerting the American people that mental illness is a critical public health problem that must be addressed immediately. As a society, we assign a high priority to disease prevention and health promotion; so, too, must we ensure that mental health and the prevention of mental disorders share that priority.

Mental illness is the second leading cause of disability in major market economies such as the United States, with mental disorders collectively accounting for more than 15% of all disabilities. Mental disorders--depression, schizophrenia, eating disorders, depressive (bipolar) illness, anxiety disorders, attention deficit hyperactivity disorder and Alzheimer's disease, to name a few--are as disabling and serious as cancer and heart disease in terms of premature death and lost productivity.

Few Americans are untouched by mental illness, whether it occurs within one's family or among neighbors, co-workers or members of the community. In fact, in any one year, one in five Americans--including children, adolescents, adults and the elderly--experience a mental disorder. Unfortunately, over half of those with severe mental illness do not seek treatment. This is mostly due to some very real barriers to access, foremost among them the stigma that people attach to mental illness and the lack of parity between insurance coverage for mental health services and other health care services.

Over the past 2 5 years, there has been a scientific revolution in the fields of mental health and mental illness that has helped remove the stigma. The brain has emerged as the central focus for studies of mental health and mental illness, with emphasis on the activities that underlie our abilities to feel, learn, remember and, when brain activity goes awry, experience mental health problems or a mental illness. We now know that not only do the workings of the brain affect behavior, emotions and memory, but that experience, emotion and behavior also affect the workings of the brain.

As information about the brain accumulates, the challenge then becomes to apply this new knowledge to clinical practice.

Today, mental disorders can be correctly diagnosed and, for the most part, treated with medications or short-term psychotherapy, or with a combination of approaches. The single most explicit recommendation I make in my report is to seek help if you have a mental health problem or think you have symptoms of a mental disorder. It is my firm conviction that mental health is indispensable to personal well-being and balanced living. Overall quality of life is tremendously improved when a mental disorder is diagnosed early and treated appropriately.

My report presents an in-depth look at mental health services in the U.S. and at the scientific research that supports treatment interventions for people with mental disorders. Summarized briefly below, it attempts to describe trends in the mental health field; explore mental health across the human life span; examine the organization and financing of mental health services; and recommend courses of action to further improve the quality and availability of mental health services for all Americans. The report's conclusions are based on a review of more than 3,000 research articles and other materials, including first person accounts from people who have experienced mental disorders.

A Vision for the Future

I cannot emphasize enough the principal recommendation of my report: Seek help if you think you have a mental health problem or symptoms of a mental disorder. But because stigma and substantial gaps in the accessibility to state-of-the-art mental health services keep many from seeking help, I offer the nation the following additional recommendations, which are intended to overcome some of these barriers:

o Continue to Build the Science Base: As scientific progress propels us into the next century, there should be a special effort to address pronounced gaps in current knowledge, including the urgent need for research relating to mental health promotion and illness prevention.

o Overcome Stigma: An emerging consumer and family movement has, through vigorous advocacy, sought to overcome stigma and prevent discrimination against people with mental illness. Powerful and pervasive, stigma prevents people from acknowledging their mental health problems and disclosing them to others. To improve access to care, stigma must no longer be tolerated. Research and more effective treatments will help move this country toward care and support of the ill--and away from blame and stigma.

o Improve Public Awareness of Effective Treatments: Mental health treatments have improved by leaps and bounds over the past 25 years, but those treatments do no good unless people are aware they exist and seek them out. There are effective treatments for virtually every mental disorder. For more information on how to take advantage of them, call (877) 9MHEALTH.

o Ensure the Supply of Mental Health Services and Providers: Currently, there is a shortage of mental health professionals serving children and adolescents, elderly people with serious mental disorders and those who suffer from mental illness-related substance abuse. There is also a shortage of specialists with expertise in cognitive behavioral therapy and interpersonal therapy--two forms of psychotherapy that have proven effective for many types of mental health problems.

o Ensure Delivery of State-of-the-Art Treatments: A wide variety of effective, community-based services--carefully refined through years of research--exist for even the most severe mental illnesses, but they are not yet widely available in community settings. We need to ensure that mental health services are as universally accessible as other health services in the continuously changing health care delivery system. We must speed the transfer of new information from the research setting into the service delivery setting.

o Tailor Treatment to Individuals, Acknowledging Age, Gender, Race and Culture: To be optimally effective, diagnosis and treatment of mental illness must be attentive to these factors.

Patients often prefer to be treated by mental health professionals who are of the same racial and ethnic background, a fact that underscores the need to wain more minorities in the mental health professions. Facilitate Entry into Treatment: Access to mental health services can be improved immediately if we enhance the abilities of primary care providers, public schools, the child welfare system and others to help people with mental health problems seek treatment. In addition, ensuring ready access to appropriate services for people with severe mental disorders promises to significantly reduce the need for involuntary care, which is sometimes required in order to prevent behavior that could be harmful to oneself or others.

o Reduce Financial Barriers to Treatment: Equality or parity between mental health coverage and other health coverage is an affordable and effective way to decrease the number of ill people who are not receiving proper treatment.

The U.S. system is extremely complex; it is a hybrid system that serves many people well, but often seems fragmented and inaccessible to those with the most extensive problems and fewest financial resources. Critical gaps exist between those who need services and those who receive them; only about 40% of those with severe disorders use any services at all.

Although research shows little direct evidence of problems with quality in mental health service programs, there are signs that programs could be better implemented, especially ones that serve children and people with serious impairment. While an array of quality monitoring and improvement methods have been developed, incentives to improve conditions lag behind incentives to reduce costs.

These inequities in insurance coverage for mental and physical health care have prompted 27 states to adopt legislation requiring parity, and compelled President Clinton to order the Federal Employees Health Benefits Program to provide parity for federal employees by the year 2001. Some localized attempts at creating parity so far have resulted in better mental health service access at negligible cost increases for managed care organizations.

Issues relating to mental health and mental illness have been overlooked or ignored in this country too often and for too long. While we cannot change the past, I am convinced that we can shape a better future.

IMAGES FROM WITHIN

Truth be told, we tend to consider mental illness in the abstract, as the misfortune of strangers. In these compelling portraits, however, photographer Marc Hauser reveals the individuality and humanity of sufferers of mental illness. They are cat owners and car lovers, uncles and neighbors. They are all clients of the Lockport Center for Behavioral Health in Will County, Illinois. A complete collection of their portraits, with text by Alisa Hauser, appears in Images From Within: Portraits of People Confronting Mental Illness (High Tide Press, 1999).

GREG GIANNINI

I'd describe myself as a regular person .... Most of the time I like taking walks around my house. Before I was living in a group home out in the country and there weren't that many stores or streets to walk on. I like walking to 7-Eleven and Mr. D's fast food.

ROSE CLARK

Sometimes I wake up so sick, but then I go to work and feel better. Being with animals makes me feel 100% better. Does that sound funny?

I love my boss. He's crazy. When he does surgery he dances, does the jitterbug. Sometimes I go into surgery with him to make sure all the animals are lying down straight and not awake. Mostly my responsibilities are taking care of the cages and general cleaning.

I've been with this program for four years. Since then I've gone back to school and gotten a job. I live in my own apartment, got two cats, and have a checking and savings account.

TONY RIVERA

When I first came to the Pastimes Cafe & Antiques I told them that it reminds me of the coffee shops in Baltimore and Maryland. They laughed and we've been friends for two yearn. They know my name when I walk in. I used to know all their names but I only come every few weeks now and I can't remember. They make me feel comfortable, like I'm not bothering anybody.

KATHY MOLYNEAUX

I didn't know I was depressed until after college. I just thought everyone felt the same way I did. I had problems sleeping, feeling down, overwhelmed, worried and not happy. My graduation from DePaul University in 1983 was a good day. After college, I worked successfully as a nurse for 13 years. I felt like I could relate to the patients because I had been there myself.

SHERYL CAUDLE

My family at first didn't understand why I was so depressed. My dad kept asking me why couldn't I be happy?... I never thought I'd be able to work again because of my illness. I've had to quit other jobs in the past, but I don't want to quit cleaning the Boxy [a local movie theater]; I want to have an apartment someday and a job in the community. Both of these things would be special to me because it would mean I've come a long way.

PATTI REID

I used to live in a house with my family, but I have a rare disorder that makes me think about the past. In 1992, I got this disorder and I couldn't drive my car anymore. I miss driving the most. My two big battles are smiling and taking my medications. Both of these are very hard.