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Archives of General Psychiatry, 12,63-70. 220 CHAPTER 4 ADULTS AND MENTAL HEALTH Contents Chapter Overview .............................................................. 225 Mental Health in Adulthood ................................................... 227 PersonalityTraits ......................................................... 227 Self-Esteem ......................................................... 228 Neuroticism ......................................................... 229 Avoidance .......................................................... 229 Impulsivity .......................................................... 229 Sociopathy .......................................................... 229 Stressful Life Events ......................................................... 230 Past Trauma and Child Sexual Abuse ........................................ 23 1 DomesticViolence...........: ........................................... 231 Interventions for Stressful Life Events ........................................ 232 Prevention of Mental Disorders ................................................ 233 Anxiety Disorders .............................................................. 233 Types of Anxiety Disorders ................................................... 233 Panic Attacks and Panic Disorder ........................................... 233 Agoraphobia ............................................................ 234 SpecificPhobias ........................................................ 235 SocialPhobia ........................................................... 235 Generalized Anxiety Disorder ............................................. 235 Obsessive-Compulsive Disorder ........................................... 236 Acute and Post-Traumatic Stress Disorders .................................... 237 Etiology of Anxiety Disorders ................................................. 237 Acute Stress Response .................................................... 238 New Views About the Anatomical and Biochemical Basis of Anxiety ............... 239 Neurotransmitter Alterations ............................................... 240 Psychological Views of Anxiety ............................................ 240 Contents, continued Treatment of Anxiety Disorders ................................................ 241 CounselingandPsychotherapy .............................................. 241 Pharmacotherapy ........................................................ 242 Benzodiazepines ...................................................... 242 Antidepressants ................................................... o .. 242 Buspirone ........................................................... 243 Combinations of Psychotherapy and Pharmacotherapy ........................... 243 MoodDisorders ................................................................ 244 Complications and Comorbidities ............................................... 244 Clinical Depression Versus Normal Sadness ................................... 245 Assessment: Diagnosis and Syndrome Severity .................................... 245 Major Depressive Disorder ................................................. 246 Dysthymia .............................................................. 246 BipolarDisorder.. ....................................................... 246 Cyclothymia ............................................................ 251 DifferentialDiagnosis ..................................................... 251 Etiology of Mood Disorders ................................................... 25 1 Biologic Factors in Depression .... .: ........................................ 251 MonoamineHypothesis ................................................... 252 Evolving Views of Depression .............................................. 252 Anxiety and Depression ................................................... 253 Psychosocial and Genetic Factors in Depression ................................ 254 Stressful Life Events ...................................................... 254 CognitiveFactors ........................................................ 254 Temperament and Personality .............................................. 255 Gender ................................................................. 255 Genetic Factors in Depression and Bipolar Disorder ............................. 256 TreatmentofMoodDisorders .................................................. 257 StagesofTherapy ........................................................ 257 AcutePhaseTherapy .................................................. 257 Continuation Phase Therapy ............................................ 261 Maintenance Phase Therapies ........................................... 26 1 Specific Treatments for Episodes of Depression and Mania .......................... 261 Contents, contjnued Treatment of Major Depressive Episodes ..................................... 262 Pharmacotherapies .................................................... 262 Alternate Pharmacotherapies ............................................. 263 Augmentation Strategies ................................................ 265 Psychotherapy and Counseling .................................... . ..... 265 BipolarDepression ............. . ..................................... 265 Pharmacotherapy, Psychosocial Therapy, and Multimodal Therapy ............ 266 Preventing Relapse of Major Depressive Episodes ........................... 267 Treatment of Mania ...................................................... 267 AcutePhaseEfficacy .................................................. 267 Maintenance Treatment to Prevent Recurrences of Mania ..................... 268 Service Delivery for Mood Disorders ........................................ 269 Schizophrenia ................................................................. 269 Overview .................................................................. 269 Cognitive Dysfunction ................................................... 272 FunctionalImpairment ................................................... 272 CulturalVariation .......... . ............................................ 272 Prevalence ............................................................. 273 Prevalence of Comorbid Medical Illness ................................... 273 CourseandRecovery ........................................................ 274 GenderandAgeatOnset .................................................. 275 EtiologyofSchizophrenia .................................................... 276 Interventions ............................................................... 279 Pharmacotherapy ........................................................ 280 Ethnopsychopharmacology ................................................ 282 PsychosocialTreatments .................................................. 283 Psychotherapy ....................................................... 283 FamilyInterventions .................................................. 283 Psychosocial Rehabilitation and Skills Development ......................... 283 Coping and Self-Monitoring ............................................ 284 Vocational Rehabilitation .............................................. 285 ServiceDelivery ............................................................... 285 CaseManagement .......................................................... 286 Assertive Community Treatment ............................................... 286 Psychosocial Rehabilitation Services ........................................... 287 Inpatient Hospitalizatioh and Community Alternatives for Crisis Care .................. 287 Services for Substance Abuse and Severe Mental Illness ............................ 288 Contents, continued Other Services AndSupports.. .................................................... 289 Consumer Self-Help ......................................................... 289 Consumer-Operated Programs ................................................. 290 ConsumerAdvocacy ......................................................... 291 Family Self-Help ................................................. .' ....... 291 Family Advocacy.. .......................................................... 292 HumanServices .............................................................. 292 Housing ................................................................ 292 Income, Education, and Employment ......................................... 293 HealthCoverage ......................................................... 294 Integrating Service Systems .................................................... 295 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 CHAPTER 4 A dulthood is a time for achieving productive vocations and for sustaining close relationships at home and in the community. These aspirations are readily attainable for adults who are mentally healthy. And they are within reach for adults who have mental disorders, thanks to major strides in diagnosis, treatment, and service delivery. This chapter reviews the current state of knowledge about mental health in adults, along with selected mental disorders: anxiety disorders, mood disorders, and schizophrenia. These disorders are highlighted largely because of their prevalence in the population and the burden of illness associated with each. The chapter then turns to service delivery, describing the effective organization and range of services for adults with the most severe mental disorders. It also reviews an array of other services and supports designed to provide comprehensive care beyond `the formal therapeutic setting. Chapter Overview Mental health in adulthood is characterized by the successful performance of mental function, enabling individuals to cope with adversity and to flourish in their education, vocation, and personal relationships. These are the areas of functioning most widely recognized by the mental health field. Yet, from the perspective of different cultures, these measures may define the concept of mental health too narrowly. As noted in Chapter 2, many groups, particularly ethnic and racial minority group members, also emphasize community, spiritual, and religious ties as necessary for mental health. The mental health profession is becoming more aware of the importance of reaching out to other cultures; an innovation termed "linguistically and culturally competent services" is ADUTS AND MENTAL HEALTH pertinent both to the field's conception of mental health and to the diagnosis and treatment of mental disorders. An assortment of traits or personal characteristics have been viewed as contributing to mental health, including self-esteem, optimism, and resilience (Alloy & Abramson, 1988; Seligman, 199 1; Institute of Medicine [IOM], 1994; Beardslee & Vaillant, 1997). These and related traits are seen as sources of personal resilience needed to weather the storms of stressful life events. Stressful life events in adulthood include the breakup of intimate romantic relationships, death of a family member or friend, economic hardship, role conflict, work overload, racism and discrimination, poor physical health, accidental injuries, and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Stressful life events in adulthood also may reflect past events. Severe trauma in childhood, including sexual and physical abuse, may persist as a stressor into adulthood, or may make the individual more vulnerable to ongoing stresses (Browne & Finkelhor, 1986). Although some kinds of stressful life events are encountered almost universally, certain demographic groups have greater exposure and/or vulnerability to their cumulative impact. These groups include women, younger adults, unmarried adults, African Americans, and individuals of lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999). Anxiety disorders are the most prevalent mental disorders in adults (Regier et al., 1990). The anxiety disorders affect twice as many women as men. A broad category, anxiety disorders include panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder, 225