Chronically Mentally Ill

The term “serious and persistent mental illness,” or SPMI, is the currently accepted term for a variety of mental health problems that lead to tremendous disability. Although commonly associated with the illness schizophrenia, the severely and persistently mentally ill include people with a variety of psychiatric diagnoses. More than just a difference of diagnoses, there is a difference in culture when people speak of SPMI. The concept of SPMI presupposes an understanding that it is about a population of severely ill people and not about a DSM diagnosis, that it should include multidisciplinary treatment rather than just a physician, that a biosocial rather than a purely medical approach is often used, and that functional outcomes, especially social and occupational, are often more important than symptomatic outcomes.

The term “serious and persistent mental illness,” or “seriously and persistently mentally ill,” grew out of the term “chronically mentally ill.” Chronically mentally ill, or CMI, was a term used to identify the patients who lived in state hospitals or other long-term institutions. With the passage of Kennedy’s Community Mental Health Centers Act in 1963, the deinstitutionalization, or “dehospitalization,” and the advent of widespread use of antipsychotic medications, care for CMI patients moved from institutional settings to community settings. Also, with successful treatment, some patients with CMI no longer had a “chronic” course of their illness. It also seemed to some that the term “chronically mentally ill” was a pessimistic and, possibly, pejorative term. Over time, the use of “severely mentally ill” or “severely and persistently mentally ill” became the accepted term for such patients.

But who are these patients? As psychiatrists who are used to diagnosing people with a standardized DSM method, how does one identify a patient who is “severely and persistently mentally ill”? In fact, there have been multiple definitions over the years leading to vastly different prevalence rates and confusion about which services to provide to which patient. One study found prevalence rates of SPMI between 4% and 88% of the population of adult patients treated at community mental health centers in Philadelphia, depending upon which definition was used. However, the most consistent definitions of SPMI include a diagnosis of nonorganic psychosis, functional disability in areas of social and occupational functioning, and a prolonged illness and long-term treatment. It includes many patients with schizophrenia, but also people with bipolar disorder, severe major depression, and, in some less frequently used definitions of SPMI, substance use and personality disorders.

The treatment of the SPMI of course includes medications, but it also includes a variety of psychosocial modalities, usually with a strong focus on rehabilitation, and services available to both mental health consumers and families. Assertive community treatment, known as ACT, is the most known and accepted psychosocial treatment program designed for an SPMI population. ACT grew out of the Program for Assertive Community Treatment, or PACT, model designed by Test and Stein as a response to the “revolving door” of repeated hospitalizations for the severely and persistently mentally ill in the early 1970s. With much research over the next 2 decades, ACT has become a standard model for comprehensive treatment of people with SPMI and is strongly lobbied for by the National Alliance for the Mentally Ill (NAMI) and others on a state and national level as a “best practice” form of treatment. The basic tenets of ACT include high-intensity community-based case management services with a low client-provider ratio, with various forms of direct assistance provided including medications, basic needs such as housing, food, and clothing, training in basic living skills, family and social support network psychoeducation, and vocational support. With the significant level of disability and functional impairment for many people with SPMI, the skills taught by ACT clinicians often start with such basic living skills such as how to navigate public transportation, how to shop for and prepare food, and how to access emergency services. The desired outcomes include not only reduced symptomatology and hospitalization but also improved quality of life and functioning in the areas of activities of daily living, social relations, and employment.

More information about this disorder can be found at WikiPedia.