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these services are not covered by private insurance and have not been developed by most private behavioral health care companies.

Any approach to reform of mental health and substance abuse care services or to the problem of accountability must reckon with these factors, which are not simultaneously present in any other substantial sector of health care services. The dynamics of the three interrelated sectors—privately funded primary and specialty health care and public health care systems—are complex and also highly idiosyncratic from state to state, community to community, and plan to plan. An additional layer of complexity comes from the historical separation of treatment systems for mental health, drug abuse, alcohol abuse, and the primary care system in both the public and private sectors.

This chapter will set out the committee's views about the unique challenges in the delivery of behavioral health care. The chapter includes a description of the prevalence and costs of mental health and substance abuse problems, the difficulties and fragmentation of the current system for the delivery of care, the role of primary care, and a description of some of the support services that are needed for the long-term management of mental health and substance abuse problems. Historical perspectives on separate systems are also provided.

EXTENT AND IMPACT OF BEHAVIORAL HEALTH PROBLEMS

Prevalence

The social consequences of mental health and substance abuse problems are much greater than generally appreciated. The prevalence of these conditions in society is quite large, and the economic burdens are substantial.

The most recent estimates of the prevalence of behavioral health disorders suggest that almost a third of the adult population experiences some impairment due to a behavioral health problem in any one year (Kessler et al., 1994). The most common problems experienced by the adult population annually are anxiety disorders (17 percent), alcohol dependence (7 percent), and affective disorders (11 percent) (Kessler et al., 1994) (see Table 3.1).

Many of the most serious and often disabling mental disorders (e.g., schizophrenia, major depression, bipolar illness, or manic depression) affect a total of 1 to 2 percent of the adult population annually. The incidence and prevalence of child and adolescent problems is not as well established, but levels of emotional disturbance that affect functioning are noted in about one of every eight children and adolescents (SAMHSA, 1996) (see Table 3.2a). Estimated annual prevalence of drug use among children and adolescents is presented in Table 3.2b.

Estimates of the impact of mental health and substance abuse problems reveal the substantial effects of these conditions. The direct and indirect costs to society have been estimated at $257 billion for substance abuse (Rice, 1995) (see Table 3.3) and $148 billion for mental illness in 1990 (Rice, 1995; Rice and



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