Serious Mental Illness

Overview

Each society has to find a solution for a vexing problem: how to deal effectively and humanely with individuals who have a serious mental illness (SMI) that might not fully respond to available treatments. This task taxes societies' allocation of resources and matters for public safety. Specific solutions are the result of historical peculiarities of time and place. In the US for example, an overly optimistic emptying of state hospitals (asylums) into poorly funded community treatment settings led to revolving door inpatient admissions but it also gave rise to recovery-oriented models of care. Encouraging progress in many countries has led to a greater level of patient involvement in care and a great reduction in the use of long-term hospitalizations and coercive tools, like seclusion and restraints (see Community Psychiatry, Chapter 67 , for details).

In this chapter, we will examine the challenges faced by physicians in caring for patients with serious mental illnesses, like schizophrenia, over the course of the long-term illness, with an emphasis on assessment and treatment goals to optimize chances for a good clinical outcome and for societal integration.

Definition and Scope of the Problem

There is no agreed-upon definition of “serious mental illness” (SMI) or “severe and persistent mental illness” (SPMI), terms that have replaced the older term “chronic mental illness” to avoid its negative connotation of untreatability and life-long institutionalization in a state hospital. SMI can be defined in general terms as any psychiatric illness that is characterized by (1) serious psychiatric symptoms (diagnostic criterion), (2) a long history of illness (duration criterion), and (3) poor psychosocial functioning (disability criterion). Implicit in the use of the terms SMI or SPMI is the assumption that patients require ongoing and often life-long psychiatric care and societal supports. Thus defined, SMI is an umbrella term for a diagnostically heterogeneous group that is not restricted to functional psychoses. While a majority of patients have schizo­phrenia, others suffer from bipolar disorder, chronic depression, or severe personality disorders ( Box 64-1 ).

Despite its heterogeneity, the term is nevertheless useful as it captures psychiatric conditions where a restitutio ad integrum (full restoration of health) is unlikely; and where illness management and treatment over long periods (for life in most cases) will thus be necessary, at great costs to patients, families, and society. The Substance Abuse and Mental Health Services Administration estimated that in 2011 there were 11.5 million adults aged 18 years or older with SMI living in the US, representing 5% of all adults. Worldwide, neuropsychiatric disorders, including schizophrenia, contribute substantially to global disease burden and are included in the top five conditions that contribute to non-communicable disease burden.

Complications of Serious Mental Illness

One glaring consequence of having SMI is a reduced life expectancy ( Box 64-2 ). As a group, patients with SMI live one or two decades less than comparable cohorts without mental illness. While some of the excess mortality stems from suicide, premature death is mostly attributable to medical morbidity, particularly cardiovascular disease. Etiological factors include a myriad of modifiable health risk factors, such as smoking and lifestyle choices; notably, both factors are also associated with poverty. For example, the Centers for Disease Control estimates that more than 1 in 3 adults (36%) with a mental illness smoke cigarettes, compared with about 1 in 5 adults (21%) with no mental illness. The percent of adults smoking cigarettes approaches 50% for those who live below the poverty line. Iatrogenic factors contributing to cardiovascular mortality that stem from the use of psychotropics and poorly coordinated care add insult to injury. To complicate life further for patients with SMI, co-morbid substance use disorders are common. In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sample, which is representative of patients with schizophrenia cared for in typical US settings, 60% of patients used substances and 37% had a current substance use disorder.

Many consequences of having an SMI can be summarized under “social toxicity” ( Box 64-2 ), which captures the pernicious, non-medical consequences of developing SMI.

A common societal complication of a serious psychiatric illness like schizophrenia is the poverty that results from illness-related challenges in attaining higher education and gainful employment. In the CATIE sample, 73% of patients reported no employment activity in the month before the baseline assessment. Patients with marginal financial resources are at risk for homelessness, and a significant number of patients with psychosis are among the homeless in Western societies. In one well-characterized sample of homeless people in downtown Los Angeles, about one-third suffered from SMI. If psychiatric treatment resources are insufficient, there is a risk that patients are unfairly criminalized and inappropriately cared for in the legal system, phenomena that have been called “criminalization of the mentally ill” and “trans­institutionalization,” respectively ( Figure 64.1 ). Finally, the likely interruption of normal adult development often precludes establishing an enduring intimate relationship, as well as sustained, meaningful social connections.