When the federal government released an important compendium of mental health data this week, the headlines proclaimed that 1 in 5 Americans over 18 had a diagnosable mental illness in the past year, and 1 in 20 had a “serious mental illness.”

But what does “serious mental illness” mean, anyway, and what are its connotations and implications when it comes to treatment? It’s a question worth asking, because it’s used differently in different contexts.

The federal government has a formal definition for serious mental illness (SMI) which classifies it as “serious functional impairment, which substantially interferes with or limits one or more major life activities”  and has occurred in the past 12 months. (The National Survey on Drug Use and Health mental health findings released this week also classified people as having mild or moderate functional impairment).

This blog focuses on young people with mental illnesses, and I noted with interest the report’s findings that among adults, those ages 18 to 25 were most likely to have a SMI. (They were also more likely than older adults to meet other indicators of mental distress, but more on that in a future post).

Although it’s treated as something of a truism among mental health advocates that those with mild and moderate mental illness are overtreated and those with SMI are undertreated, this data shows that 60 percent of the latter received some kind of mental health services, compared to about 40 percent of the former.

Fifty-four percent of those with SMI received medication. Although the report didn’t break pharmaceutical treatment down by age group, among those with SMI, 18 to 25-year-olds were the least likely to receive mental health services compared to older adults.

This is all very interesting, but making sense of the data is something of a challenge because of the various ways “serious mental illness” is defined in different contexts. While surveys like NSDUH use impairment as their metric, “serious mental illness” is, in my experience,  often used to refer to diagnoses where psychosis or mania is present: bipolar disorder, schizophrenia and schizoaffective disorder (a combination of schizophrenia and mood disorder symptoms).

But that’s not always the case. Even the National Alliance on Mental Illness, or NAMI, the chief U.S. advocacy group for the mentally ill, skirts the issue a bit. In a fact sheet on mental illness, NAMI also includes as serious mental illnesses OCD, depression, PTSD, panic disorder and borderline personality disorder.

A young woman with bipolar disorder I know who majored in psychology and has done mental health advocacy, once made the distinction this way: There are conditions that any mainstream doctor is going to insist on treating with medication, she said – hence the psychosis and mania threshold. Those conditions that could be treated without meds are usually not included.

Her definition makes a lot of sense to me, intuitively. But once you get into the business of suggesting that medication is, somehow, “optional,” you’re treading on perilous ground, turning what ought to be a case-by-case, individual determination into a categorical one.

This is just the objection I have when critics of medication declare one group or another to be “overmedicated.”

The blogger Natasha Tracy, who has bipolar disorder, wisely recognized the delicacy of this issue in a recent post on what the “worst” mental disorder is. She writes:

“…No matter what the diagnosis, no matter what the illness, no matter what the pain scale, no matter what the statistics say, it doesn’t matter. Because when you’re on the floor of your kitchen with a razor blade in your hand, you know one thing for sure – your mental illness is surely the worst in the world for you at that moment. And you’re absolutely right.”

I think that is beautifully – and very diplomatically put. But, to bring the topic back to the focus of this blog, what about when your condition is well-managed with medication? Does a formerly “severe” mental illness become “mild” or “moderate”? Does it disappear entirely?

By the federal government’s definitions – which requires the illness to have been present in the past 12 months – it does. But as someone trying to assume an identity that incorporates, accommodates and yet doesn’t surrender to psychiatric problems, it’s a tricky question to answer.

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