Tuesday, December 10, 2013

Who are the Mentally Ill? Please take my Brief Survey!

We hear about "the mentally ill" all of the time.  They shouldn't have guns.  They die an average of eight years younger than those without mental illness.  We don't have enough hospital beds for them.  They're filling our prisons and some of them are homeless... oh, the list goes on.

Defining the term is important because we single this group out for all types of discriminatory practices related to employment, driving, gun ownership, and even the ability to enter the United States for a vacation (at least on a few occasions).  We also single this group out for special benefits such as being allowed to take their dogs on airplanes or to receive benefits from the government in the form of disability payments,  health insurance in the form of Medicare, and entry into specialized day programs and vocational rehabilitation programs.  But there is no agreed upon definition of who is mentally ill, and the Diagnostic and Statistical Manual ( DSM) lists hundreds of disorders, limiting its utility as the determinant of who is mentally ill and therefore eligible for discrimination, stigmatization, or special benefits.

I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better.  Finally, many people who get treatment don't identify themselves as mentally ill because they are too busy identifying themselves as being Mary's husband, Tom's mother, a doctor or a lawyer or a barber, master gardener, avid Raven's fan, or any other aspect of identity that consumes time, generates income, and adds value to society.   It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy. 

So I'm going to ask you.  Who are the mentally ill?  Please take my quiz only once, and please ask your social media followers to take the survey-- it should only take a few minutes.   It's am important question, one that guides all types of legislation and policies and I'd love to know what you think.  And thank you!  Comments on the post are welcome.



Je Suis said...
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Dinah said...
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Steven Reidbord MD said...

Great survey Dinah. I hesitate to comment for fear of changing your results, but I can't resist. I've never been comfortable with the term "mental illness" and hardly ever use it.

Medical sociologists long ago differentiated "disease" and "illness." The latter is a subjective sense of feeling ill, and assuming a socially-sanctioned "illness role" — being relieved of work, accepting care, etc. Illness is subjective, it's not an objective determination. Thus, I find little reason to label anyone mentally ill solely due to diagnosis, except in cases where miserable symptoms are extremely common and hard to shake (schizophrenia) or are manifestly present by definition (intermittent explosive disorder). But even then I'm not sure.

I therefore disagree with NAMI, and ironically do agree with political positions that limit firearm sales and such to "the mentally ill." Because anyone in a subjectively debilitating emotional state (illness) shouldn't be handling guns, whether or not they have a diagnosis.

Dinah said...
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Je Suis said...

"Is NAMI the final word?"

No, but NAMI is a resource, and allows a definition, which, in the end, is what matters. Not everyone will agree on what constitutes a mentally ill individual, but not everyone has to - what's important is how the lawmakers view it; and they will use resources such as NAMI as a reference. It doesn't matter whether its subjective or objective - and of course it's subjective, a diagnosis is based on the subjective symptoms experienced by the patient - since there's no objective test for the definitive diagnosis of mental illness (or disease, if you prefer)
it's all subjective. So, the lawmakers want to write laws - laws supported by at least some mental health professionals (see Dr. Reidbord's comments) to limit firearm sales to the "mentally ill" (as defined by Dr Reidbord) - how do they do that? Simply put, they don't. Because they can't. They can't write a law that prevents a person with a "mental illness" (or disease, or issues, or whatever term you like..) from purchasing a firearm while "in a subjectively debilitating emotional state" because they would be unable to enforce it. How could they? It could easily be argued that they were not in that state at the time of purchase. Maybe they are off their meds, or their subjective state fluctuates, or they had a one time occurrence, but it has returned years later, or well, any number of possibilities, really. No, in reality, if they are going to write the law, they have write something concrete (well, as concrete as legalities allow, there always seems to be a loophole somewhere...); one that draws a line somewhere. And that somewhere will be based on diagnoses and interactions with the mental healthcare (and I used that term very loosely) system (such as 72 hour holds and emergency room judgments). In order to appear to be a concerned lawmaker, they will write broad legislation that covers everyone with the same stifling blanket. And it will be based on 'facts", like the definitions offered by NAMI and others. Because that is the only way they can, and damn the harm it causes to otherwise innocent, and non-dangerous, individuals caught up in the hysteria, and stigmatized again by a system that is supposed to be helping them.

This is why I posted the NAMI definitions in the first place: because our individual ideas and opinions on what constitutes mental illness don't matter in the grand scheme of things, but a legal definition does; and that definition will come from places like NAMI, an organization that offers an easy definition and claims some expertise on the subject of mental illness, a gift of sorts to a lawmaker that just wants to appease constituents by throwing some undesirables to the wolves. Or lions, whatever - pick your metaphor; it's all the same in the end. Someone loses. Someone suffers. And someone else is appeased.

Dinah said...

Je Suis, I took down your comment, not because it was troublesome, but because you listed a "definition" of mental illness and I want to access people's beliefs and gut reactions, ... I was concerned readers would see the list and definition and it would bias the survey.

Anonymous said...

On medication for 16 years, have been hospitalized for severe depression. Have a PhD and a career and family. Still consider myself mentally ill.

EmmaM said...

THis is a really interesting survey. I have worked in MH for nearly 20 years in various social care roles as a MH social worker and now as a development officer for a small mental health charity. I have also experienced mh problems. "illness" is a medical model definition however mental health problems as I prefer to call them are not necessarily best served by the medical profession. My understandinf of how I would define someone as having a MH problems would be if the medical profession defined them as such - because they have the power to do that, The term to me is about socialisation rather than being a descriptive term for people's condition. When someone's mh interferes with someone's own perceived quality of life then it becomes a problem - if it doesn't then it is a lifestyle choice.That's not to belittle the medical interventions as I know from both personnal and professional experience how vital they are rather it highlights the difficulties that occur when we attempt to categorise someone as mentally ill

Anonymous said...

Je Suis, I agree with you that the only definition that matters is the legal definition. That's what I'm faced with now. In a little over 2 years I have to renew my drivers license. The question on the application, "Within the past two years, have you been diagnosed with, been hospitalized for or are you now receiving treatment for a psychiatric disorder?"

Apparently, I was fine when I didn't see the psychiatrist, but now that I do I'm in trouble. Two years from January I will have to answer that question which means if I don't want to lie and don't want to have to be in their government database, face an evaluation or whatever else they come up with, then I have to stop seeing the psychiatrist in January, avoid treatment for 2 years until my license is renewed.


Shaughan Abbott said...

I suffer from a medical condition, called Mesial Temporal Lobe Epilepsy,caused by a stroke either in the womb,birth canal or just as I left it!This condition can easily be mistaken for schizophrenia,it wasn't actually formally diagnosed until 1999 and I am 49 yrs old. I have a co-condition which pre-disposes me to depression and anxiety, so you can understand that I had many years of misdiagnosis of my mental Health issues.
I believe that I have mental health issues,I believe I can BECOME mentally ill, but it hasnt stopped from studying from a degree in psychology, I believe that I have an Insight that I can bring to the table as a psyxchologist!

Anonymous said...

This is interesting, and it made me think about my own ideas and attitudes.

The first thing I wanted to say in a comment was that there's a difference between poor mental health, and being mentally ill. But then I thought - well, what is the difference?

I'm not sure where the line falls exactly, but I suspect the difference is all about life events leading to poor mental health, versus mental illness leading to a poor life experience.

I consider myself mentally ill, and I didn't even have to pause to answer that one.

Anonymous said...

In my opinion, the definition of mental is now so loosely applied that anyone who encounters a crisis in the life and has trouble dealing with it, is deemed mentally ill.

An extreme example - Some who commits suicide due to being economically ruined and seeing no way out of the mess. Even though this person had no history of any mental illness, some alleged expert will claim that this person had to have had a lingering depression that caused it.

In my opinion, this rush to label all crises mental illness come heck or high water prevents people from getting the necessary help. So I definitely agree with Dr. Reidbord's post.

Regarding guns, I don't think anyone should have one. Even if you aren't "mentally ill", it just takes a second for for your emotional state to become volatile such as getting into an argument with a stranger. Think about how many deaths from guns have occurred as the result of this situation.


Anonymous said...

I have always been troubled by defining mental illness as either episodic versus chronic. Is one episode, even a debilitating episode, treated into remission still count as mental illness? Now that I think about it, almost all mental illness is chronic in nature. Otherwise, people tend to trump up a single episode into "growing pains."

rpblank said...

Mental illness is a medical condition just like any other illness. If you are in treatment for a diagnosed mental illness, you are "mentally ill". Just like if you are in treatment for cancer, you have cancer. Both can also be recurring conditions that require ongoing monitoring after the initial symptoms subside. The real issue is the stigma attached to being labeled as "mentally ill" and the damage that stigma does to the individual with the condition.

Anonymous said...

Another way of thinking about "Who are the mentally ill?" is to think about "Who are not the mentally ill?" I believe the continuum of "normal" mental health is wide, and may very well include some people taking medication and/or receiving psychotherapy to successfully treat a psychiatric condition.

Anonymous said...

I wish you would have had allowed for a comments section at the end...

I don't understand why we can't consider things like depression or PTSD the same as "getting sick" in the traditional physical sense. Because, in many case, you can get better.

Then you have chronic conditions, like diabetes or schizophrenia, which may be managed well, then something comes along to knock your blood sugars or thinking processes out of whack and you need an intervention (possibly hospitalization) to get yourself back on track. That's a CONDITION. In fact, we can call everything a MEDICAL CONDITION since it requires some medical intervention to achieve new balance.

If you had something like depression or cancer, and it was treated and you're fine now, then you're healthy.

Joel Hassman, MD said...

Just curious, is this part of your research for a pending book?

Perhaps an oversimplification, but, isn't illness about being dysfunctional and feeling unhealthy?

Lady Jedi said...

I paused on some of those survey questions. Who are the mentally ill? Can you really be mentally ill if you are fully functioning...even if you are on meds? Joel Hassman makes a good point. Don't you have to be dysfunctional and unhealthy to be ill? I thought schizophrenia was a no brainer...but then I rethought it and wondered about how stable the person is on meds. I think I just checkmarked it anyhow. I didn't check mark Borderline or Antisocial just because I don't know that some of those people really are mentally ill. I wouldn't personally call Dexter or Hannibal Lecter mentally ill. Darth Vader was Borderline(?), but I don't remember thinking "mentally ill" when he was destroying the Jedis or cutting off Luke's hand. Princess Leia and Luke both turned out fine. Luke almost went dark, until he saw that he was becoming just like his dad (that scene from Return of the Jedi where Luke realizes he and his dad are both missing a hand from battle). Luke chose the light. I think some things that look like mental illness are really just personal choices. We must all choose to stay away from the dark side of the Force and cling to the light even when it's hard.

I think, for me, I have to look more at how the person is feeling. Do they feel ill? Does it matter that they needed drugs to feel better? Do they look ill to everyone else? Hmmm.

May the Force be with all of you.

Anonymous said...

This is great!

I don't think of myself as having a mental illness -- despite taking meds, seeing a therapist, and in
the past having a bunch o' hospitalizations, ECT, etc. I have a susceptibility or tendency to depression, which I have to be on the lookout for and still may not be able to stop from becoming a full-blown episode given the right stressors. But at the moment I'm as healthy as they come. :-)

People who I think of as mentally ill are chronically so and functionally impaired, either because they haven't be treated or the treatment is inadequate. I put the drug treatments for schizophrenia in the "inadequate" category.

But what's recovery if the label "mentally ill" stays with you forever? Not for me.

clairesmum said...

Survey done. My comments - as a nurse with a graduate degree in psychology- and as someone with major depression recurrent, in sustained remission and PTSD ( managed with psychotherapy, good self care, and PRN benzo and ambien) I believe mental illness includes anything other than adjustment disorders. Use of psych meds by primary care providers is not definitive for diagnosis, in my opinion. Any licensed prescriber can prescribe psych meds. I also firmly believe that brain based illnesses can be treated and kept in remission (few or no sx, little if any progression of pathophysiologic changes) just like asthma, HTN, GERD, seizures, etc. and like those illnesses, no one treatment regimen works for all, and for some treatment, no treatment works very well. All of our dis-eases include disturbances starting at the cellular level, even tho we don't fully understand any disease completely. The division between mental and physical illness is arbitrary and based on stigma, as is the distinction between mental illness and substance use/misuse disorders.

Anonymous said...

Thank you for this test which I found very thought provoking. I ended up not being able to answer most of the questions. They seemed to be valid questions, and yet there was something wrong with most of them. As if they were missing the point.

I have suffered from major depression on three occasions since I was a teenager. I am now sixty. Over the years I have been treated for this depression with medication, shock treatment and psychotherapy, and hospitalised on several occasions. On the last occasion the psychiatrist told me that I am seriously mentally ill and will need to be on medication for the rest of my life.

I don't consider myself mentally ill, and took exception to the psychiatrist's words.

I am an academic, and am generally considered to have one of the most original intellects at my university. I am also an award winning writer.

My depression feels like an integral part of me and my thinking and my creativity. It stems from traumatic events outside myself in my childhood, and is a way of dealing with these events. It has given me depth, the kind of depth that comes from suffering, which most religions consider to be the thing that most makes us human, and therefore godlike. I do not want it taken away from me.

To call it an illness means that it needs to be treated and if possible removed. Although I have suffered greatly with it, I consider it a gift. It is one of the most valuable parts of myself.

Anonymous said...

"Mentally ill" is an inappropriate term. What is 'mental'? Is it a body part? No, it is not. Only physical 'parts' can get ill IMHO. However people can and do have "brain function disorders".

I also find it highly offensive that addictions are considered 'diseases'. An addiction is a lifestyle choice that results in a dependance. How is that a disease? Cancer is a disease - one does not make a lifestyle choice to get it, drug and alcohol addictions are not diseases, they are brought on by an individual's specific actions.

Unknown said...

I have two friends who have had serious 'breakdowns' or 'episodes' (I don't know what else to call it) where they were completely out of touch with reality, not due to drugs, legal or illegal. Both had to be hospitalized, where they were given drugs for psychosis. One, whose episode exhibited a variety of psychotic behaviors, rather quickly 'came back to herself.' There is no other way to explain it. She has not had another episode, and it's been 10 years. The other is on a drug for being bi-polar, and is back to his regular life, with all symptoms gone, and no side effects. The doctors talk of getting him off the drugs, in case it was a single episode. I certainly wouldn't classify either one as mentally ill today, but I certainly would have at the time of their episodes.

Steven Reidbord MD said...

I just posted my thoughts on this question, and pointed readers to the survey:

jesse said...

This is a thought provoking issue. My own thoughts on this are very similar to Dr. Reidbord's. I don't think in terms of "mental illness" the great majority of the time and then only for the severest types of problems such as schizophrenia.

Many of the comments here bring out that the term is not understood the same way by different people, so why use a term that is not clearly understood? I don't think that by using it we reduce stigma, because people hear it so differently.

There is just too much prejudice regarding the term. In most everything else we tend to use a different term or word when one gets too loaded with prejudice, and often that change also reflects an effort to be more accurate. The most obvious example of this is in the area of race: there are words we now never use; we do not try to educate people to use the old terms more open-mindedly. It is also true in regard to retardation, sexual orientation, terms referring to place of origin, and so on.

Sometimes, on the other hand, a medical term that is direct and straightforward comes to replace outmoded euphemisms.

But with "mental illness" the term is too diffuse and loaded with prejudice.

Psycritic said...

Dinah, thank you for this thought-provoking topic! I've posted a brief patient story illustrating my own struggle with the term "mentally ill" over on my blog.

Anonymous said...

The logic here is a bit flawed....under whose terms are you defining "mental illness". If you want to say medical model, or legal definition, those carry very defined thresholds. If you are looking at something as a psychoanalyst, the term "mentally ill" isn't really used as we speak to internal structures and character issues (though often we are using different words to mean similar things). I think the biggest issue here is the one of conceptualization -- someone may be mentally ill, or have a primitive internal structure (or, or, or, or, etc), but how the clinician conceptualizes the patient is what matters -- symptoms are symptoms and you can use any labels you wish to categorize and describe but what is more important is the why, the benign curiosity about the purpose, function, meaning and impact of the symptoms. Lay people hear the word mental illness and have negative consultations, naturally due to media presentation etc, but more sophisticated folks hopefully take a less reductionist, less pejorative view.

Mary L. Flett said...

Love this method of surveying beliefs! I noticed as I completed the survey that I had very definite ideas about what was mental illness, and they weren't consistent. As I continue to reflect, I find myself using the metric of functioning rather than a disease process. This is a challenge when I am asked to "name" something. thanks for the opportunity to think about this.
Mary L. Flett, Ph.D.

Greg S said...

I am a psychiatrist with many years experience. I love the idea of your survey and I went ahead and filled it out as best I could. However from my viewpoint the survey in its present form was impossible to answer because for almost all the questions the only true answer is "depends on the severity". Is depression after a breakup of a relationship mental illness? I don't think so. Is mild-moderate chronic depression handled pretty well by self-help books mental illness? I don't think so. Is moderate to severe depression that requires continued medication mental illness? Probably. Is schizophrenia? Yes, unless in the rare case it has completely resolved.

Dinah said...

Psycritic: love your post, and thank you.

Dr. Flett: Thank you, kind words are always appreciated.

Last Anon and Dr. S: Clinically, I believe the term is useless; we help those who come requesting help (or those whom others drag in who are in need of help) and there is so much edge to a poorly defined term. But policy makers, mental health advocates, and border guards use it, and they don't ask "what is the severity?"... So I thought I might ask. Results soon.

Thank you to everyone who has participated!

Anonymous said...

In my humble opinion... the term mental illness and the way it is applied by physicians implies that the brain is not part of the body. Disorders or conditions which are or seem to be physiologic might better be classified as neurological. In the past alzheimers disease, epilepsy, e.g. were mental illness. Now that they are not...there is more treatment and less discrimination. "Psychiatric" meds or treatments might still be used, but when illnesses are recognized as bonifide medical illness...I think things get better with treatment, research, reimbursement, etc.
So, then what is mental illness, imho it would be those things which seem less about physiology and more about circumstances and experience which impact behavior, thinking, etc. For example things like borderline pd, or addiction, pedophilia,bulimia ...there may be some element of physiology...but these things seem closer to learned behavior