Getting Serious About Mental Illnesses

For the past few years, National Institute of Mental Health (NIMH) has been increasingly focusing their research on serious mental illness (SMI). What does “SMI” mean? If some illnesses are considered “serious,” does that mean that others are not? If some mental illnesses are not classified as serious, does that mean they aren’t significant? Does everyone with a diagnosis of schizophrenia or bipolar disorder have SMI? What about anorexia nervosa or borderline personality or post traumatic stress disorder (PTSD)? Do these qualify as SMI? Should NIMH focus their efforts on the best science that will reduce the tremendous morbidity and mortality associated with all mental illnesses or should they limit themselves to those causing the most disability? To answer these questions, a little history might help.

Where did the term “SMI” come from? In the 1992 ADAMHA Reorganization Act (P.L. 102-321), Congress directed the Secretary of Health and Human Services to develop a federal definition of SMI to aid in the estimation of SMI incidence and prevalence rates in states that were applying for grant funds to support mental health services. “Adults with a serious mental illness are persons: age 18 and over, who currently or at any time during the past year, have a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R, that has resulted in functional impairment which substantially interferes with or limits one or more major life activities. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects.” While the federal definition of SMI is specific to adults, there is an analogous definition of “serious emotional disturbance” (SED) for children. Both SMI and SED definitions focus on the DSM diagnosis, plus degree of impairment.

As one can see, the “official” definition of SMI is very inclusive. Recently, SMI has been a subject of conversation in the wake of recent shooting tragedies. Discussions about SMI and violence, directed towards self or others, are usually focused on schizophrenia and bipolar disorder, and sometimes major depressive disorder. Violence is an extreme (and rare) negative outcome of disorders like these, warranting particular emphasis, but it is not the only negative outcome to consider. For example, anorexia nervosa can be fatal, yet eating disorders have understandably been excluded from discussions about SMI.

In fact, all mental illnesses have the potential to be impairing and meet the meaning of “serious” in the sense of the federal definition. NIMH supports an extensive portfolio on all aspects of mental illness, from basic research to clinical investigations,  to common disorders in men and women affecting adults and children in a diversity of populations. To better understand how NIMH research addresses SMI, the next few sentences provide a quick break-down of their overall portfolio. In 2012, nearly 13% of their total budget was mandated for research on HIV/AIDS, and about 5% went to administrative costs: Support for the Institute, funding hospitals and clinics, and general overhead. Research on disorders that can be disabling (including autism) covered 51% of non-AIDS portfolio but if one looks at the broad range of research that could shed light on new diagnostics or new treatments, then one could consider that 81.3% of NIMH non-AIDS portfolio was dedicated to SMI research.

NIMH investment in basic science, usually unrelated to a specific diagnostic category, accounts for the 30% interval between their SMI portfolio defined narrowly (51%) vs. broadly (81.3%). They continually talk about serious mental disorders as brain disorders. What NIMH doesn’t say is that their knowledge of how the brain works remains far behind their understanding of other organ systems. Developing tools for understanding the brain, identifying the major circuits important for behavior, and deciphering the language of the brain are critical investments for NIMH in order to make progress on diagnostics and therapeutics for SMI. Similarly, basic behavioral science can give NIMH the tools to detect the earliest signs of schizophrenia or autism. They do not count these among their SMI portfolio, yet investing in basic science may be NIMH most important investments for people with serious mental illness.

So when NIMH states its increasing their focus on SMI, what they really mean is that they are investing in the best science that can reduce the most disability and mortality. Some of these investments are focused on biomarkers or new treatments for schizophrenia, bipolar disorder, and major depressive disorder but they also are committed to supporting science that will give a much deeper understanding of brain and behavior. That, in the long run, is the most direct path to “paving the way for prevention, recovery, and cure.”

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