Who is mentally ill?

My fellow psychiatrist and blogger Dinah Miller raised this simple yet profound question on Shrink Rap the other day.  Who is rightfully labeled mentally ill?  Is it anyone with a psychiatric diagnosis, past or present?  Anyone with currently active psychiatric symptoms?  Anyone receiving psychiatric treatment?  Dr. Miller observes that “the mentally ill” is an oft-cited demographic.  It carries much social weight — negative in the form of discriminatory practices related to employment, driving, and gun ownership, and positive in the form of entitlements, disability status, and the like. With so much riding on this label, knowing exactly how and to whom it applies seems crucial.

“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.”

She includes a brief survey that she hopes everyone — mental health professionals, patients, and neither/both — will fill out.  At this point, if you’d like to complete her survey before I bias you with my own thoughts, go ahead and do that, then come back here.

Ok, here is my view of “the mentally ill.”  It’s a term I’ve never felt comfortable with, and thus rarely use, owing to what I view as imprecision.  Certain groups define mental illness to suit their purposes.  For example, the National Alliance on Mental Illness (NAMI) declares that “mental illness is a medical condition,” and then provides a list of selected mental disorders they believe qualify as “mental illness.”  This in turn leads to the rather incredible claim that “one in four adults… experiences mental illness in a given year. ”  However, NAMI’s definition does not reflect common usage, nor does it comport with the way “illness” is used in the rest of medicine.  More commonly, mental illness is a conceptually slippery, undefined euphemism that makes it easier to talk about restricting the rights of a subpopulation, or conferring benefits on them, without being too specific about whose rights are affected and why.

Definitions can be descriptive or prescriptive.  The former is how a word or phrase is actually used, the latter how it is properly used.  In actual use, “mentally ill” seems most often to mean manifesting a severe, observable psychiatric condition that renders the person unable to live normally.  Florid psychosis, mania, and severe obsessive-compulsive symptoms are clear examples.  However, contrary to NAMI, even fairly severe depression is equivocal, and neurotic anxiety, mild depression, and most personality disorders are clear non-examples. Typical discourse around rights and entitlements conflates current mental illness with high likelihood of having mental illness in the near future.  So a person can be temporarily free of impairment and yet still be subject to the restrictions and entitlements of someone in the throes of impairment.

As mentioned, this is not how “illness” is used in the rest of medicine.  (I’m about to get prescriptive here.)  Medical anthropologists long ago differentiated disease (or diagnosis) from illness.  The former may be asymptomatic and completely unknown to the patient.  Examples include the “silent killer” hypertension and an asymptomatic brain tumor.  In contrast, illness is a subjective state of feeling medically unwell, plus the psychological, social, and cultural consequences of this state.  Those suffering a cold, “the flu,” or nausea feel ill, even if the exact underlying disease is not well characterized.  Illness leads to a socially defined “sick role”: the ill person is relieved of his or her usual duties, accepts help from caregivers, is more needy and less autonomous than usual, etc.  If “mental illness” were used the way “illness” is used in the rest of medicine, ego-syntonic conditions, e.g., most mania, would be termed disorders but not illnesses.  Conversely, mild to moderate depression and anxiety would be unequivocal mental or emotional illnesses, even lacking a specific diagnosis.

Since “mentally ill” obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it’s self-descriptive.   In my view, “the mentally ill” harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  “Mental illness” is more of a rhetorical flourish, a bit of hand-waving when it’s difficult or inconvenient to pin down specifics.