Shrink Rap Today

Three psychiatrists explain their work

Defining Who We Mean by "The Mentally Ill"

Is there any consensus on what it means to talk about those with mental illness?

Who are Those Mentally Ill People?

You hear about them regularly: the mentally ill. President Obama has declared that we need to keep guns from the hands of the mentally ill, advocates say we need more services for them, and the National Alliance of Mental Illness tells us that one in four Americans are affected by mental illness.

When a person is designated as “mentally ill,” it may allow for special entitlements: smaller classrooms and one-on-one aides for severely disturbed children, on-going disability payments from the federal government, Medicare benefits, and the right to bring a comfort pet on airplanes. The mentally ill are also designated for stigma and the assumption of limitations and dangerousness. They are kept from certain occupations, prevented from owning guns, and turned away at our borders.

Clinically, the term is meaningless. As a psychiatrist with over twenty years experience, I still don’t know who these mentally ill people are. In psychiatry, we treat those who come seeking help. There is no test at the door to divide the mentally well sufferers from the mentally ill sufferers and to direct them down separate corridors. Some patients can be very disturbed during an episode of illness, and with treatment, they soon become well. Community surveys show that just over half of Americans will suffer from at least one episode of mental illness during their lives. The designation of being mentally ill is as meaningful as a coin toss: heads and you’re one of “them.”

What factors contribute to the designation of “mentally ill?” Is it who offers the treatment: a psychiatrist, a psychotherapist, or a primary care doctor? Is the type of pills a patient takes? The diagnosis? Whether the patient has been hospitalized, voluntarily or by commitment?

One way to answer such questions is through the channels of scientific research: obtain a grant and institutional review board approval, question a given population with validated tools, statistically analyze the results and publish a peer-reviewed paper. Another option—and the one I chose—is to post a survey on a blog and solicit responses on social media. It’s not validated research, but it’s fast and it’s free.

So who did 696 respondents believe these “mentally ill” people to be? Very few people (17 respondents, or 2%) thought that seeing a therapist for psychotherapy classifies someone as mentally ill. That number rose to 61 respondents, or 9%, if the patient saw a psychiatrist for psychotherapy. If psychiatric medications were prescribed by a primary care doctor, 20% believed this meant a patient was mentally ill. That number rose to 37% if the patient received medications from a psychiatrist. So, getting treatment from a psychiatrist may be one factor that leads people to a designation of mental illness.

In terms of psychotropic medications, sleeping pills had the lowest association with mental illness, while antipsychotics and mood stabilizers had the highest association, and anti-depressants and anxiety medications were in the middle.

For diagnoses, the most common illness associated with mental illness was schizophrenia with 620 votes. Bipolar disorder was a a close second. Depression was associated with mental illness by 328 respondents, notably fewer than the 409 who deemed pedophilia to be a mental illness. Gender identity disorder and attention deficit disorder were both much lower on the list, with 136 votes and 119 votes, respectively.

Forty-four percent of respondents thought having been in a psychiatric hospital on a voluntary basis meant one was mentally ill, but the percentage jumped to 70% if the hospitalization was involuntary. Half thought a serious suicide attempt constituted mental illness, an interesting statistic in view of the fact that most gun deaths are suicides, not homicides, and the term is used freely with respect to firearms’ legislation. The symptom most associated with the label of mental illness were hallucinations and delusions, but even there, 11% of respondents did not think people who have these symptoms are mentally ill.

The survey I created was a social media experiment. And while the numbers generated are not validated science, they still demonstrate that when it comes to discussions about those with mental illness, we don’t have a consensus as to who it is we are actually talking about.

Dinah Miller, M.D., is a psychiatrist and writer in Baltimore, Maryland. She is co-author of the book Shrink Rap: Three Psychiatrists Explain Their Work.

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