Public Mental Health

Mental disorders have historically been characterized within the personal domain, to be individually diagnosed and treated. This focus has lead to the rapid and widespread development and provision of pharmacologic and psychosocial treatments that, despite their efficacy in treating mental illness in individuals, have had limited impact on the global burden of mental illness. Public health and population-level approaches have progressively contributed to our understanding of the etiology of mental illness, which is increasingly being translated into preventive efforts. Public Mental Health (1), which was edited by W. W. Eaton and includes chapters authored by faculty from the Bloomberg School of Public Health at Johns Hopkins University, provides a comprehensive introduction to this topic through a thorough review of current public health findings in the mental health domain that is accompanied by a thoughtful discussion of current interventions and the potential for the future effectiveness of preventive efforts. Public Mental Health is one of relatively few edited collections of readings in psychiatric public health that is specifically oriented toward presenting the diverse and essential body of empirical knowledge within the field. The editor claims in the introduction that, as opposed to the more methods-oriented collection Psychiatric Epidemiology (2) and the policy-oriented Population Mental Health: Evidence, Policy and Public Mental Health Practice (3), Public Mental Health “covers the breadth of the emerging field of public mental health more systematically” (1, p. xv). This stands in unique contrast to the text edited by Susser et al. (2), in which the authors openly state that they aim to provide a methodological framework for future studies rather than a summary of the current and past findings of psychiatric epidemiology. Public Mental Health is divided into sections that focus extensively on the descriptive epidemiology of psychiatric conditions, the commonly studied mechanisms of risk, and the mental health services and health care system of the United States. There are also notable chapters on methodology, cultural considerations, prevention, the legal system, and future aims of studying mental health within the public health field. Chapter 1 begins by analyzing the disease burden of mental disorders through review of 12-month prevalence and associated disability reported in third-generation psychiatric epidemiology studies. In addition to reviewing the previously reported burden of common mental disorders, this chapter provides one of the only reviews of epidemiologic findings with eating disorders and disorders of childhood onset, and it makes itself approachable to the nonclinical reader by providing Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for several example diagnoses. Chapter 2 then discusses the shortcomings of these DSM-IV diagnoses when used as a public health tool, highlighting that the “field guide” of symptom profiles does not consider the nature, cause, or mechanisms of risk underlying psychiatric conditions. Clinical diagnoses facilitate consistency across epidemiologic studies but are not the most efficient way to study causes and mechanisms, as has previously been noted (4, 5). The authors claim that considering the causal mechanisms that underlie disorders will help to bridge the gap separating public health and psychiatry, as the approach has done with general medicine, and therefore recommend a shift from the DSM-IV model toward on that differentiates disorders by their causal mechanisms. Finally, the first section concludes with the poignant Chapter 3, in which the authors detail cultural considerations on how risk and resiliency factors may vary by culture and how some disorders are more biologic and therefore universal whereas others are more culture bound. They then present a discussion of symptoms that are mediated by culture, including the content of delusions and hallucinations in schizophrenia and the existence of culture-bound syndromes that are not assessed using DSM-IV criteria. The second section, which comprises 2 chapters, concisely considers public health methods, perhaps reflecting the aims of the text in focusing on the content rather than the methods of the field. Chapter 4 covers the assessment of psychological distress and mental disorder in the population through an overview of the reliability and validity of methods used in third-generation studies, with an interesting discussion on the problematic measurement of need for care and demand for services. Chapter 5 provides a brief overview of randomized controlled trials, nonexperimental causal inference, latent variables, sampling, and imputation of missing data. Although the specific section on methods is understated, methodological issues continue to be discussed throughout the chapters as appropriate. The third section, Descriptive Epidemiology, has 2 chapters in which the authors examine the life-course population dynamics of mental disorders, as well as their associations with sociodemographic factors. The authors of Chapter 6 acknowledge the methodological difficulty of establishing life-course trajectories of mental health conditions given