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TABLE 1.1 Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54)

Behavioral Health Problems



No. of People


All behavioral health problems (i.e., mental disorders, alcoholism, and drug addiction)



Any mental disorder



Any substance abuse or dependence (i.e., alcohol and illicit drugs)



Both mental disorder and substance abuse or dependence



NOTE: Prevalence data have been collected from the National Comorbidity Survey (NCS), a Congressionally mandated survey designed to study the comorbidity of substance use disorders and nonsubstance use-related psychiatric disorders in the United States. The survey was administered by the staff of the Survey Research Center at the University of Michigan between 1990 and 1992. NCS surveyed 8,098 noninstitutionalized participants with a structured psychiatric interview conducted by lay interviewers using a revised version of the Composite International Diagnostic Interview (CIDI). CIDI is a structured diagnostic interview based on the National Institute of Mental Health's (NIMH's) Diagnostic Interview Schedule, which can be used by trained interviewers who are not clinicians (Kessler et al., 1994).

SOURCE: Kessler et al. (1994) and SAMHSA (1995).

physical health, and for mental health and substance abuse care there also have been few alternatives to hospitalization. In the late 1980s, the majority (70 percent) of mental health funds spent by Medicaid and private insurance went for inpatient care, leading many researchers, clinicians, and advocates to question the imbalance and to search for policy changes. Only the introduction of managed care arrangements has led to a significant shift away from costly and often unnecessary inpatient stays to a more appropriate range of outpatient and community-based care. In sum, behavioral health care offers purchasers the potential to spread existing resources farther by paying for less intensive (and less expensive) treatment strategies that can return patients to a reasonable level of functioning, such as being able to return to work or school (England and Vaccaro, 1991).

The controversies in managed care are less about the goal of cost reductions and are more about the ways in which cost reductions are achieved. Methods of cost control include authorizing only certain practitioners who are under contract to provide services to an enrolled population, reviewing treatment decisions, closely monitoring high-cost cases, reducing the number of days for inpatient hospital stays, and increasing the use of less expensive alternatives to hospitalization (Iglehart, 1996; Shore and Beigel, 1996).

In the committee's view, managed care strategies are not inherently harmful

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