Organizational change seldom occurs all at once. More often it is preceded and facilitated by a series of smaller changes. The U.S. Centers for Disease Control and Prevention (CDC), founded in 1946 with a focus on communicable disease, historically considered mental health to fall outside of its mission. Having evolved from a World War II-era malaria control program, CDC expanded in the following decades to address most major types of disease and injuries, as well as health promotion and disease prevention. By the late 1980s CDC had evolved into the nation's leading public health agency. Despite this evolution a widely held set of underlying assumptions about CDC, namely an organizational paradigm, persisted that continued to frame mental health as being outside of CDC's mission. This brief history describes how that paradigm was challenged and superseded by a new paradigm recognizing that mental health is part of CDC's public health mission.
One program influencing the early history of mental health at CDC was a program that did not consider itself a mental health program—CDC's intentional injury prevention program (1,2). The program was developed in the 1980s in response to high morbidity and mortality rates associated with intentional injuries. Citing the need for complementary approaches beyond mental health, the program emphasized public health approaches, such as surveillance, risk factor identification, evaluation, and intervention (2).
By 1995 several CDC programs were addressing one or more mental health-related topics (2,3,4,5). Still, most CDC programs considered mental health to be outside of the agency's mission. Public health practice at CDC to some extent reflected clinical, research, and societal practices of the time, which tended to neglect mental health and treat it as being separate from physical health. Other factors discouraging mental health's inclusion in individual CDC programs were tradition and competition for limited resources.
In 1994–1995 expert groups asked by management to enhance inclusion of behavioral sciences in CDC's work declined to include mental health. Within those groups, Pamela Tucker, M.D., and I spoke against such exclusion.
Widely accepted public health paradigms had long supported the inseparability of physical and mental health—for example, George Engel's biopsychosocial model of medicine and the World Health Organization's 1978 Declaration of Alma-Ata, which defined health as "a state of complete physical, mental and social wellbeing." By 1995 the largest public health hotline in the world, the CDC National AIDS Hotline, was learning that staff needed to be trained in mental health in order to effectively respond to many callers' information needs. Likewise, the Agency for Toxic Substances and Disease Registry was considering mental health in addressing the needs of communities exposed to toxins. At CDC there was accumulating quality-of-life surveillance data related to mental health, and work was proceeding in other evolving mental health-related areas, such as adverse childhood experiences and aging. Still, for most of the agency, mental health continued to be considered as not being related to CDC's mission through the time of release of the landmark report on mental health by then-Surgeon General David Satcher in late 1999 (6).
The 1999 Surgeon General's report initially drew little attention at CDC, so I requested and received approval to educate CDC staff about the report. I began by organizing a CDC-wide scientific meeting on mental health. Thus, on February 17, 2000, a CDC-wide meeting of 100 participants considered whether CDC should be involved in mental health and explored what roles CDC did and might play.
I cited four pieces of evidence that day supporting the argument that a leading public health agency like CDC should be involved in mental health. The first piece of evidence cited was the importance of mental health for all persons, as part of overall health (6). The second piece was the interconnectedness of mind and body, of physical and mental health (6); thus the impossibility of fully addressing the physical diseases that CDC was traditionally charged with addressing without giving attention to mental health. The third was the enormity of mental illness as a public health problem in its own right—affecting one in four Americans and their families (6). And the fourth was the potential impact of mental illness on a person's ability to understand and practice health promotion, disease prevention, and self-treatment practices—thus the need for public health planning to take into account special needs of persons with mental illness. These concepts were new to many at CDC that day, but they were subsequently included in numerous presentations across the agency.
Still, two major concerns cited quietly but often after that meeting were the belief that most at CDC would never accept that mental health was part of CDC's mission and the belief that even if CDC were to accept that mental health was part of its mission, Congress, the White House, and the nation's lead mental health services agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), would not. Many CDC managers remained uncertain as to whether it would be permissible for CDC funds to be used to address mental health, or they simply believed that they could not.
In 2000 CDC had a small number of mental health experts on its staff, most of whom had been hired because of their expertise in other areas of public health, which constituted their primary assignments. By August 2000 the CDC Mental Health Work Group had gained support of CDC management in transforming itself from a grassroots effort of CDC scientists to a unique cross-CDC collaborative entity that was in part a CDC scientific work group and in part something more. The work group received encouragement from the Carter Center, which like CDC is based in Atlanta, and from Former First Lady Rosalynn Carter, a long-time advocate for mental health.
The CDC Mental Health Work Group, like most of the agency's work groups, did not have a budget, dedicated staff, or formal command authority. Members carried out work group duties in addition to their other work responsibilities, adding value to CDC without added cost. However, the CDC Mental Health Work Group was different from other CDC work groups in that it was actually filling the role of the mental health program office or center that CDC did not have.
The CDC Mental Health Work Group provided agencywide leadership, technical consultation, CDC representation to other agencies, expertise for scientific and public health projects involving mental health, and educational seminars illustrating mental health's relevance to public health. To integrate mental health into CDC's standard approach to public health, the work group used organizational change techniques, such as education, modeling, mentoring, empowerment, diplomacy, catalysis, promotion of program-relevant mental health expertise across the agency, and partnership building.
CDC joined the World Federation for Mental Health and other national and international organizations in cosponsoring the Inaugural World Conference on the Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders, December 5 to 8, 2000, at the Carter Center. This was the first time that CDC ever funded a mental health conference through its conference grants program. Before this mental health conference was held, the conference grants program operated under language stating that topics such as mental health and substance abuse were not related to CDC's mission. As a condition for CDC's contributing to the Inaugural World Conference, conference organizers had to promise that the conference would directly emphasize important links between mental disorders and the physical illnesses that CDC normally addressed. The CDC Mental Health Work Group participated actively in the conference, and with help from the National Mental Health Association (now Mental Health America), the work group also organized a separate mental health conference at CDC, which was held December 7, 2000, in conjunction with the Inaugural World Conference. Both events resulted in dialogue between CDC leaders and national and world mental health leaders that had not previously occurred.
In 2001 the CDC Mental Health Work Group established CDC's first mental health Internet site (www.cdc.gov/mentalhealth). This site provided concise information about mental health and links to the Web sites of mental health agencies for more detail. The existence of a CDC mental health site conveyed to the public and to public health partners that mental health is an issue warranting individual and public health attention.
After the September 11 terrorist attacks of 2001 CDC Mental Health Work Group members provided consultation to the agency regarding some of the newly evolving employee, emergency responder, and public health needs. The work group continued to catalyze recognition that mental health is a part of CDC's public health mission and growing attention to mental health across CDC's centers and activities in the context of CDC's unique public health role (7,8).
The work group emphasized from its beginnings that it could not meet all the mental health challenges CDC should address and requested funding for mental health planning, evaluation, communication, enhanced surveillance, and research. CDC managers indicated that funding was unavailable but that CDC might devote more resources to mental health in the future if the group's work proceeded well. Various options, for example, funding the work group or a mental health program support office or center, were put forth by the work group. The work group also suggested that each component of CDC support and build its own unique mental health capacity, while collaborating with and taking advantage of the unique mental health expertise of other CDC components and other agencies.
The CDC Mental Health Work Group led a CDC Science Leadership Forum on Mental Health on November 28, 2006. This was a meeting of CDC scientific and management leadership staff at which CDC's involvement in mental health and the rationale for it were presented, along with recommendations for the future. For example, needs for attention to mental health in CDC's HIV-AIDS, correctional health, child health, suicide prevention, chronic disease, bioterrorism, and disaster preparedness efforts were discussed. Mental health was noted to be relevant to all CDC centers and overarching goals. There was consensus at the forum that CDC should devote more attention to mental health.
In early 2007 the CDC Mental Health Work Group and the Financial Management Office gathered information on all CDC mental health projects for the first time. CDC's then-director, Julie Gerberding, later referred to and shared summary information from that effort with Congress after being asked by a Congressman from Ohio whether CDC was addressing the issue of stress (9). In April 2007 CDC added language to the Health Impact Planning Guide, the management information system instruction book for all CDC project officers, indicating that mental health is a part of CDC's public health mission. Project officers were requested, although not required, to list projects with major mental health components in a newly created section of the system.
On September 6, 2007, the CDC Mental Health Work Group held the first agencywide meeting on mental health surveillance, bringing together scientists from across CDC who had worked to include mental health in various existing public health surveillance systems. SAMHSA Center for Mental Health Services Director A. Kathryn Power told those scientists that not only did she not mind if CDC addressed mental health but that SAMHSA valued CDC's growing collaboration in the national mental health system transformation effort and that such participation was CDC's responsibility.
From the time I first informed SAMHSA about the CDC Mental Health Work Group in 2000, SAMHSA had indicated support. After the final report of the President's New Freedom Commission on Mental Health in July 2003 (10), CDC became a partner in SAMHSA-led national mental health system transformation efforts and was ultimately given a representative on the Federal Executive Steering Committee for Mental Health, which was convened on January 31, 2006. In the course of that committee's deliberations from 2006 through now, CDC's growing attention to mental health drew praise, and no agency ever objected to CDC involvement in addressing mental health.
On June 13, 2008, then-SAMHSA Director Terry Cline visited CDC with his senior leadership team, and they met with CDC's director and other CDC leaders and expressed pleasure with the value of the collaboration between the two agencies. The directors and other leaders of both agencies agreed on the importance of each agency's work to the other's mission and stated their intent to continue to increase collaboration in the future in ways that synergistically support the missions of both agencies. During that meeting SAMHSA praised the accomplishments of the CDC Mental Health Work Group—a work group CDC scientists had once hesitated to form, fearing SAMHSA would object.
Today CDC engages in a variety of scientific activities that address mental health as an accepted part of the agency's public health mission. Such activities represent only a small fraction of CDC's work, but they have become more common in recent years. CDC's growing acceptance of mental health as part of its purview has been synergistic with other efforts to dissipate stigma against addressing mental health in medical facilities, public health departments, and communities in the United States and internationally.
The previously accepted paradigm indicating that mental health was not part of CDC's mission has been replaced with a new paradigm recognizing that mental health is a part of CDC's mission. Much work remains to be done by CDC, the nation, and the world in order to address the enormous mental health challenges that currently exist. Mental health remains an important, though underaddressed, aspect of public health.
The author is a career CDC medical officer and psychiatrist and the founding chair of the CDC Mental Health Work Group. The author thanks all who contributed to the paradigm change reported in this brief history. Opinions are not necessarily limited to official opinions of CDC.
The author reports no competing commercial interests.