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Post by Former NIMH Director Thomas Insel: Getting Serious About Mental Illnesses

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For 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.

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: (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 important for behavior, and deciphering the language of the brain are critical 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 run, is the most direct path to “paving the way for prevention, recovery, and cure.”