What is serious mental illness in adults and what is not?

Serious mental illnesses are a small subset of the 300 mental illnesses that are in DSM. While it is fair to debate where the line between serious mental illness (SMI) and poor mental health is, the extremities are clear. The Center for Mental Health Services defined SMI as

mental illnesses listed in DSM that “resulted in functional impairment which substantially interferes with or limits one or more major life activities.” (CMHS 1999)

 By all accounts, serious mental illnesses include “schizophrenia-spectrum disorders,” “severe bipolar disorder,” and “severe major depression” as specifically and narrowly defined in DSM. People with those disorders comprise the bulk of those with serious mental illness. However, when other mental illnesses cause significant functional impairment they also count as a serious mental illness.  

According to the National Institute of Mental Health, serious mental illness is relatively rare, affecting only 5% of the population over 18. Serious mental illness includes schizophrenia; the subset of major depression called “severe, major depression”; the subset of bipolar disorder classified as “severe” and a few other disorders.

Schizophrenia (NIMH defines all schizophrenia as “severe”):  1.1% of the population (FN 1)
The subset of bipolar disorder classified as “severe”:  2.2% of the population (FN 2)
The subset of major depression called “severe, major depression”:  2.0% of the population (FN 3)

Therefore total “severe” mental illness in adults by diagnosis: 5.3% of the population (FN 4)

US mental health spending and mental health non-profits focus almost exclusively on people who do not have serious mental illness, rather than those who do. This is the single major problem with the US mental health system. Money is not lacking. Prioritization is.

Three Reasons I Won't Celebrate Mental Illness Awareness Week

1. MIAW is based on the false premise that there is stigma to having a mental illness.

This first full week in Week in May is being celebrated as Mental Illness Awareness Week. In celebration, well meaning mental health advocacy organizations are busy hosting events to reduce the “stigma” of mental illness. But there is no ‘stigma’ to having a mental illness. Serious mental illnesses, like schizophrenia, are real biologically based disorders that are no ones fault. Serious mental illness or ('consuming mental health services') is not, “a mark of shame or discredit”, or “a mark or token of infamy or disgrace”.

It used to be said there was stigma to being “black”, “gay”, “short”, ”tall”, “lefty”, “righty”, inny, outy or having cancer.

But over time all these groups found a cure: they simply decided that there was no stigma to having being gay, lesbian or lefty or having cancer. It was not, as some claimed, a "mark of shame" or "token of disgrace."

They killed stigma and recognized that what they were really suffering was discrimination. It’s time for mental health advocates to do the same. Fight discrimination (what others do to you) and stop running ads about how you feel about yourself (suffer stigma).

2. MIAW diverts attention away from those who are most seriously ill

The second reason I won’t celebrate MIAW is that it diverts attention away from the most seriously ill. The anti-stigma campaigns are premised on the belief that the key to reducing ‘stigma’ is to convince the public that “the mentally ill are just like you and me” and “with proper supports can recover and become productive members of society”. Hence, only the high functioning and happy appear in the promotional materials and PSAs. They focus on the 40% who may during their life have a mental “health” issue.

The efforts focus on mental “health”, not mental “illness”.

But what about the three percent to five percent of Americans who are the most seriously mentally ill -- like those suffering from untreated schizophrenia or treatment-resistant bipolar disorder? And what about the homeless psychotic, eating out of garbage cans, sleeping in cardboard homes, and living with festering wounds under layer after layer of filthy clothes because they have a mental illness than makes them unable to help themselves? You won’t find them in the Mental Illness Awareness Week PSAs.

Trying to gain sympathy and resources for serious mental illness, by only displaying the highest functioning individuals, is like trying to end hunger by showing the well-fed. And new research shows it doesn't work. There is no less 'stigma' today than when these efforts started.

Try this test. Google "mental illness" and Google "mental health". Look how many results are returned.

Hardly anyone is still fighting for people with serious mental illness. In fact, it is no longer even considered politically correct to use the term "mental illness". One must say "mental health". You are not allowed to say "patients", you are supposed to say "consumers" as in "consumers of mental health services."

The homeless people we see under twelve layers of smelly lice-infected clothing talking to themselves, fearing their hallucinations as they forage through garbage cans looking for food are not "consumers". They should be patients, but no one wants them.

MIAW is premised on the false belief that the major problem we face is that people won’t self-identify.

That is small potatoes and possibly true for those with mental “health” isssues, but it is not true for those with serious mental illnesses.

People with serious mental illness almost always self-identify. They do it through their psychotic ramblings, delusional explanations, ritualistic behaviors. It is not hard to identify people with serious mental illness, it is hard to get them treatment.

In 1955 there were 340 public psychiatric beds available per 100,000 U.S. citizens. By 2005, the number plummeted to a staggering 17 beds per 100,000 persons.

If someone is so ill they don’t know they are mentally ill, current law requires them to become ‘danger to self or others’. Rather than prevent violence, the law requires it.

While services are available to a wider swath of people with “mental health” issues as we medicalize normality, services are rarely available for the most seriously ill.

By spreading the false meme that the problem is identification, rather than the provisioning of services for the most seriously ill, Mental Illness Awareness Week celebrants—as well intentioned as they may be—do the seriously ill great harm.