The Seriousness of Mental Illness
Where did the term “SMI”
F or the past few years,
we at NIMH have been
increasingly focusing
our research on serious
mental illness (SMI). You
can see the term SMI in
recent blogs as well as in
publications from NIMH. But
what does “SMI” really
mean? If we call some
illnesses “serious,” does that
mean that others are not?
And 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
PTSD – do these qualify as
SMI? Should we focus our
efforts on the best science
that will reduce the
tremendous morbidity and
mortality associated with all
mental illnesses or should we
limit ourselves to those
causing the most disability?
To answer these questions, a
little history might help.
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: (1) age 18
and over, (2) who currently
or at any time during the past
year, (3) 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, (4)
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.” Federal
Register Volume 58 No. 96
published Thursday May 20,
1993, pages 29422-29425.
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 you can see, the “official”
definition of SMI is very
inclusive—though I imagine
that when people talk about
SMI these days—they don’t
have the Federal Register
definition in mind. 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 following the
events in Newtown,
Connecticut.
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, from
rare to common disorders, in
men and women, affecting
adults and children, in a
diversity of populations. To
better understand how NIMH
research addresses SMI, let
me provide a quick break-
down of our overall portfolio
using figures from 2012. Last
year, nearly 13% of our total
budget was mandated for
research on HIV/AIDS. And
about 5% went to
administrative costs: support
for the Institute, funding our
hospital and clinics, and
general overhead. Research
on disorders that can be
disabling (including autism)
covered 51% of our 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 our
non-AIDS portfolio was
dedicated to SMI research.
Our investment in basic
science—usually unrelated to
a specific diagnostic
category—accounts for the
30% interval between our
SMI portfolio defined
narrowly (51%) vs. broadly
(81.3%). We continually talk
about serious mental
disorders as brain disorders.
What we don’t say is that our
knowledge of how the brain
works remains far behind our
understanding of other organ
systems. Developing tools for
understanding the brain,
identifying the major circuits run, is the most direct path to
important for behavior, and “paving the way for
deciphering the language of prevention, recovery, and
the brain are critical cure.”
investments for NIMH in
order for us to make progress
on diagnostics and
therapeutics for SMI.
Similarly, basic behavioral
science can give us the tools
to detect the earliest signs of
schizophrenia or autism. We
do not count these among our
SMI portfolio, yet investing
in basic science may be our
most important investments
for people with serious
mental illness.
So when we say that NIMH
is increasing our focus on
SMI, what we really mean is
that we 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 we
also are committed to
supporting science that will
give us a much deeper
understanding of brain and
behavior. That, in the long