Serious Mental Illness

Oliver Freudenrich, MD, Mark Viron,MD, and Derri Shatsel, MD, MPH
Key Points

Five percentof adult in the US suffer from a serrious mental illness (SMI),
which is defined as a psychiatric illness that persists and is naccompanied

by functional disability.
Moderen, patient
-centered treatment occurs in recovery-oriented
community settinga annd includes peer support, family involvement, and

chronic disease self-management.

The treatment goal for SMI is not a cure but achieving the lowest
symptom burden with the best functioning (remission) while living a

healthy and meaningful life as a valued member of society (recovery).

Patient with SMI are at risk for medical complications and societal

disadvantages, driven in part by continuing stigma.

Preventing medical morbidity and mortality (particularly cardiovascular
disease) in patients with SMI is a important as addressing psychiatric
problems, as medical illness is a primary contributor to the staggering 10
to 20 year premature mortality seen in

this population with

moltimorbidity.
Optimal rehabilitation needs to accompany optimal pharmacotherapy to
prevent chronic disability as a late-stage manifestation of SMI. Optimal
pharmacotherapy attempts to reduce symptoms and to prevent illness
relapses, so that functional gains can accrue over time and chances for bad

outcomes are minimized.

Globally, societies struggle to create legal frameworks that balance the
protection of society from dangerous patient with a respect for patient
autonomy that does not inadvertently neglect suffering.

Overview
Each society has to find a solution for avexing problem: how to deal
effectively and humanely with individuals who have a serious mental illness

(SMI) that might not fully respond to avaliable treatments. This task taxes
societies allocation of resources and matters for public safety. Specific solutions
are the result of historical peculiarities of time and place. In the US for example,
an overly optimistic emptying of state hospitals (asylums) into poorly funded
community treatment settings led to revolving door inpatient admissions but it
also gave rise to recovery-oriented models of care. Encouraging progress is many
countries has led to greater leveln of patient involvement in care and a great
reduction in the use of longterm hospitalization and coercive tools, like seclusion
and restraints.
In this chapter, e will examine the challenges faced by physicians in caring
for patients with serious mental illness, like schizophrenia, over the course of the
longterm illness, with an emphasis on assessment and treatment goals to optimize
chances for a good clinical outcome for societal integration.
DEFINITION AND SCOPE OF THE PROBLEM
There is no agreed-uponn definition of serious mental illness (SMI) or
severe and persistent mental illness (SPMI), terms that have replaced the older
term chronic mental illness to avoid its negative connotation of untreatability
and life-long institutionalization in a state hospital.1 SMI can be defined in general
terms as any psychiatric illness that is characterized by (1) serious psychiatric
symptoms (diagnostic criterion), (2) a long history of illness (duration crterion),
and (3) poor psychosocial functioning (disability criterion). 2 Implicit in the use of
the terms SMI or SPMI is the assumption that patients require ongoing and often
life-long psychiatric care and soccietal supports. Thus defined, SMI is in umbrella
term for a diagnostically heteregeneous group that is not restricted to functional
psychoses. While a majority of patients have schizophrenia, others suffer from
bipolar disorder,, chronic depression, or severe personality disorders (Box 64-1)`
Despite its heterogeneity, the term is nevertheless useful asn it captures
psychiatric conditions where restitutio ad integrum (full restoration of health) us
unlikely and where illness management and treatment over long periods (for life
in mostcases) will thus be necessary, at great costs to patients, families, and
society. The subtance abuse and mental health service administration estimated
that in 2011 there were 11,5 million adults agde 188 years or older with SMI
living in the US, representing 5% of all adults.3 Worldwide, neuropsychiatric

disorders,

including

schizophrenia,

contribute

substantially

to

global

diseaseburden and are included in the top five conditions that contribute to noncommunicable disease burden.4-5
COMPLICATIONS OF SERIOUS MENTAL ILLNES
One glaring consequence of having SMI is reduced life expectancy(Box
64-2). As a group, patients with SMI live one or two decades less than comparable
cohorts without mental ilness.6-8 while some of the excess mortality stems from
suicide, premature death is mostly attributable to medical morbidity, particularly
cardiovascular disease.9-10 Etiological factors include a myriad of modifiable
health risk factors, such as smokingand lifestyle choices, notably, both factors are
also associated with proverty.11-12 For example, the Centers for Disease Control
estimates that more that 1 in 3

adults (36%) with a mental illness smoke

cigarettes, compared with about 1 in 5 adults (21%) with no mental illness. The
percent of adults smoking cigarettes approaches 50% for those who live bellow
the poverty line.13 Iatrogenic factors contributing to cardiovascular mortality that
stem from the use of psychotropics 14 and poorly coordinated care add insult to
injury.15-16 To complicate life further for patients with SMI, co-morbid substance
use disoredersare common. In The Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) sample, which representative of patient with schizophrenia
cared for in typical US settings, 60% of patients used substances and 37% had a
current substance use disorder.17
Many consequences of having SMI can be summarized under social
toxicity (Box 64-2), which captures the pernicious, non-medical consequences of
developing SMI.
A common societal complication of a serious psychiatric illness like
schizophrenia is the poverty that results from illness-related challenges in
attaining higher education and gainful employment.18,19 In the CATIE sample,
73% of patients reported no employment activity in the month before the baseline
assessment.20 Patients with marginal financial resources are at risk for
homelessness, and a significant number of patients with psychosis are among are
among the homeless in Western societies. 21 In one well-characterized sample of
homeless people in downtown Los Angeles, about one-third sufferd from SMI. 22 If
psychiatric treatment resources are insufficient, there is a risk that patients are

unfairly criminalized and inappropriately cared for in the legal system,

phenomena that have been called criminalization of the mentally ill and
transinstitutionalization, respectively (Figure 64.1).23-25 Finally the likely
interruption of normal adult development often precludes establising and enduring
intimate relationship, as well as sustained, meaningful social connenction.
BOX 64-1 Broad Definition of Serious Mental Illness
1. Primary psychiatric diagnosis (diagnostic criterion)
Any psychiatric illness ( excluding primary substance use disorders and
organic disorders )
2. Prolonged illness duration and treatment needs (duration criterion)
12 months
3. Functional disability (disability criterion)
GAF score < 60
GAF, General Assessment of Functioning.
Based on operational definition by Substance Abuse and Mental (SAMHSA) in :
Kessler RC et al. Screening for serious mental illness in the general population,
Arch Gen Psychiatry 60(2): 184-189, 2003.
COMPREHENSIVE ASSESSMENT
A comprehensive psychiatric and medical diagnostic assessment is critical
for successful treatment in order to avoid medical-psychiatric and social sequelae
(Box 64-3). Often, collateral information in the form of discharge summaries
from prior hospitalizations or discussion with family members will be necessary
to piece together the overall illness course and psychiatric tratment history.
Special attention must be given to identifying and characterizing any treatment
experince lithium, clozapine, or electroconvulsive therapy (ECT). Even in patients
with significant paranoia or memory problems, a diagnostic interview that
includes a life focuses on where and with whom the patients lived (including
periods of homlessness), traumatic life events, and achieved developmental
milestones is usually posible and provides invaluable clinical information and the
grounds for establishing initial rapport. Given the substansial prevalence of drug
use, a detailed substance use is distant (e.g, prior injection drug use that would
increase the risk for hepatitis C or human immunodeficiency virus (HIV)
infection). Given increased mortality from cardiac disease, risk factors from

cardiovascular disease should be elicited specifically. A detailed smoking history,

including and assessment of the motivation to quit, is important. Last, head
trauma should be asked about as part of a comprehensive assessment of potential
factors that impact neurocognition. The physical exam, enhaned byy nlaboratory
studies, needs to document the presence or absence of tardive dyskinesia and
components of the metabolic syndrome (waist circumference and/or weight, blood
presuare, dyslipidemia blood sugar control). No assessment is complite without a
risk assessment of bothh suicide and violenc, based on the patients history. In
addition traditional risk factors for suicide (e.g substance use, depression and
hopelessness, medial illness, social losses), insight into the nature of illness ad its
ramifications for life plans should be assessed in schizophrenia as another
possible risk factors.26 Active substance use, historical incidents of violence,, as
well as sociopathy and a current affective state of anger helpful factors to estimate
the risk of violence in psychotic patients. 27,28 Simply asking a patient his or her
self-perception of violence risk may add benefit to a risk assessment. 29 A history
of legal problems can have real-world implications (e.g ineligibility for housing or
jobs). Clinicians should attempt to determine if a criminal record reflects
sociopathy, an opportunity crime, drug-related activity, or the direct consequence
of a mental illness.
A medical-psychiatric diagnostic assessment alone insufficiencent without
also considering and patients strengths, hopes, and dreams as well as the
subjective quality of life. In addition, iti is necessary to assess the familial, social,
and economic resource available to promote social connection, restoration of
functioning , and autonomy. The appreciation of each individual patients
particular circumstance might evolve over time as particular limitations or
unforeseen stregths or resources surface. Similarly, the optimal level of care in the
least-restrictive nsetting needs to be determineed on an ongoing basis.
An important area requring continuing assessment is the patients
adherence to medication and his or her understanding and beliefs about the role of
medication in his or her treatment. Adherence can be divided conceptually into a
motivational-attitudinal aspect and real-world behavior. In motivated patients who
fail to adhere (unintended nonadherence), it is important to determine obstacles to

better adherence (e.g, cognitive difficulties, medication side effects, inability to

pay for medications). In patients who deliberately decline medication (intended
non-adherence), it is important to understand reason for rejection (e.g, poor
treatments efficacy with high side-effect burden, delusional beliefs about
medication, denial of illness). Figure 64-2 provider examples of factors that
contribute to poor treatment adherence, broken down into treatment attitude and
treatment barriers. Adherence is not an all-or-nothing phenomenon but can be
partial (e.g, intermittent medication adherence, acceptance of rehabilitation but
bot of medication).
BOX 64-2 Mediccal-psychiatric and Social Toxicities from Serious Mental Illness
MEDICAL-PSYCHIATRIC TOXICITIES
Premature death from preventable causes due to :
Suicide
Violence
Medical disease (cardiovascular disease)
Accidental drug overdose
Mediacal co-morbidities
SOCIAL TOXICITIES
Interrupted schooling
Loss of career
Loss of peers and friendships and families
Criminal Record
Social exclusion due to stigma and self-stigma

BOX 64-3 Comprehensive Assessment of Serious Mental Illlness

Diagnostic psychiatric assessment
Present of psychosis
Non-psychotic symptom clusters (negative symptoms, affective symptoms)
Neurocognitive examination (executive function, working memory, abstraction)
Insight into illness, including capacity to accept or reject treatment
Risk assessment: violence and suicide
History of suicide attempts, chronic suicidality, depression and demoralization

History of violence and legal problems, impullsivity, anger

Diagnostic Medical assessment
History of head injury
Iatrogenic problems from antipsychotics: neurological symptom, metabolic
syndrome
Infectious disease: human immunodeficiency virus, hepatitis, tuberculosis
Risk factors for cardiovascular disease: hypertension, diabetes, dyslipidemia,
smoking history
Wellness assessment: weight (BMI), physical activity, diet
Assessment of functional capacities (strenghts and weaknessess)
Treatment motivation
Functional ability to parcitipate in treatment and rehabilitation
Assessment of psychosocial adjustment
Hitory of psychosocial adversity (homelessness, trauma, poverty)
Work history and potential
Relationships with family mebers and friends
Estimate of financial security
Meaningful community activities
Assessment of quality of life
Physical pain, medical illness burden, depression and demoralization
Assessment of adherence
Attitude towards treatment, barriers, actual adherence behaior

TREATMENT AND RECOVERY GOALS

For patients with SMI, the overarching treatment goal is not ngate
ecssarily a cure but rather ongoing care to mitigate the effects of having a chronic
mental illness. This approach requires that a clinician look beyond symptoms an
pay attention to funtion and qualiy of life. In the language of medicine, remission
with regard to symptoms (i.e, sustaained, with only minimal symptoms) and
function (i.e, return to previous levels of funtioning) are measurable goals to strive
for30.31 in the languange o persons with lived experience, recovery (i.e, living a
meaningful and healthy life despite an illness) is and attitude and process that
counteracts nihilism in the face of psychiatric adversity.32,33 Thus defined, goals of
remission and recovery provide a framework for goals that patients, their families,
and clinicians can negotiate and agree upon. Both setting over-ambitious goals
and setting the bar too low are mistakes that cannot always be anticipated but
evolve over time, value can still be found in supposed failures in such
scenariors.34 Extending treatment framework beyond psychiatrists, nurses, and

social workers, to include family, community, and peer support, is a necessary and
logical step in comprehensive care for SMI.
To achieve the best outcomes, treatment needs to be optimal (with regard
to timing, type and intensity), comprehensive and integrated (rehabilitation with
medical and substance use treatments), and culturally sensitive. Not pursuing
optimal treatments (e.g, clozapine for refractory schizophrenia or involuntary
treatment, when warranted) can contribute to disability and impede recovery.
Lengthy hospitalizations should be minimized to prevent secondary symptoms
associated with institutionalization (e.g, lack of initiative), but they may be
necessary for a small subset of individuals with SMI, who, despite aggresive
outpatient efforts, cannot remain safely in community setting.
Clinicians can focus treatment efforts on several broads, not mutuallyexclusive categories, which follow.

Potential adherence :
Attitude
Lack of insight
Poor therapeutic alliance
Poor treatment efficacy
High side-effect burden
Critical view of psychiatric

Implementation obstacles :
Barriers

Logistics and cost

Chaotic environment
Poor cognition
Stigma
Actual adherence :
Behavior
Full/partial/none

Establising a Collaborative Treatment Relationship

Current trends in the provision of care to ppatients with SMI focus on
empowering patients to take an active role in management of their illness.
Establishing shared golas is a first step to engagement with patients. Patients need
to be involveed in decision-making about their treatment plans are put together in
the spirit of person centered care, with family involvement if desired. 35
Psychoeducation for families (including programs run by families themselves 36)
can be an important adjunct of psychiatric treatment as family members are given
tools for how to be assist in the care of a family members with SMI. The greatest
benefit of psychoeducation lies in reduced hospitalization rates, but it can also
lead to better treatment satisfaction. 37 Community resources (e.g, peers, church
and recovery centers) can be used to engage patients.38 Last, having a good
working relationship is one important factor that predicts treatment adherence.

39,40

Some intrinsic aspects of illness, including cognitive limitations and negative

symptoms,41 can impide motivation for treatment recognizing these as symptoms
of illness rather than as personality flaws will create a more empathic approach to
treatment engagement.
Preventing Suicide
Suicide is mayor cause of premature mortality in SMI. 42 For schizophrenia,
it has been estimated that 4,9% of patients die from suicide, the risk of sucidice is
highest in the early years of illness but it always remains higher than in the
general population.43 Psychotropics that have shown benefit for the reduction of

suicidality are lithium for bipolar disorder 44 and clozapine, which is FDAapproved for the treatment of suicidality in schizophrenia spectrum conditions. 45
Spesific factors that increase the suicide risk (e.g, substance use and depression or
demoralization) can be targeted. Selective serotonin reuptake inhibitors (SSRIs),
for example, have been shown to reduce suicidality in patients with
schizophrenia.46
Preventing Violence
Prevention of legal problems is a legitimate treatment goal, as patients
should not have to suffer legal consequences that result from suboptimally-treated
mental illness. To this end, clinicians might have to pursue assisted and and
involuntary treatment options, such as outpatient commitment or conditional
hospital discharges. Pharmalogic approaches may have direct utility in reducing
the ris of violence, clozapine has been shown to have anti aggresive efficacy that
does not appear to be related to its antipsychotic properties.27
Preventing Late-stage Psychiatric Disease and Disability
Frequently, patients with SMI present to care in later stages of illness,
where only tertiary prevention is possible. However, secondary prevention (e.g,
reducing periods of untreated illness through early detection) offers hope for
identifying patients in earlier stages of illness, with milder symptoms and less
disability.47 To reduce further loss of function, clear treatment goals for patients
with SMI are relapse prevention and prevention of hospitalizations. Evidencebased treatments including family-focused treatment48 and maintenance treatment
with lithium or antipsychotics, greatly reduce relapse risk for patients bipolar
disorder49 or schizophrenia50 respectively, so rehabilitation can occur againts a
background of psychiatric stability. Not offering the most effective treatments
when indicated (e.g, ECT for catatonia or clozapine for refractory psychosis) are
avoidable mistakes that can lead to poorly treated

psychiatric illness with

attendant social ramifications. Polypharmacy can be sign of inadequate

pharmacotherapy if a treatment that is more difficult to administer (.g, clozapine
or ECT) is avoided.51

In order to achieve the goal of preventing late stages of illness, optimal

pharmacotherapy

needs

to

be

accompained

by

optimal

rehabilitation.

Unfortunately, the latter is frequently limited by lack of non-pharmacological

treatment resources (e.g, cognitive-behavioral therapy for residual psychosis). A
mayor obstacle to favorable outcomes can be poor treatment adherence. While
some adherence problems can be overcome with education, support and
persistence, a significant barrier can be lack of insight, not only into the nature of
the psychiatric illness but also into the benefit from tratment or the need for
tratment.

52

This anosognosia-like deficit characterizes a significant minotiry of

patient with schizophrenia and shows little response to conventional engagement

attempts.53 Such afflicited patients often evade optimal treatment, or they receive
no treatment at all. An element of coercion can become unavoidable even in
recovery-oriented services.54 Despite apparent face validity, interventions often
recommended for thr treatment of patients with schizophrenia when adherence is
in question (e.g, the use of long-acting antipsychotics) have shown little if any
benefit when studied inn randomized trials55 Patient selectio might be critical.
Preventing Medical Morbidity and Mortality
Most patient require treatment with psychotropics that can have a host of
iatrogenic problems, some of which are preventable with appropriate monitoring
and preventive interventions. Primary amongst these side effects are metabolic
problems associated with antipsychotics. Unfortunately, guideline-concordant
monitoring for antipsychotic-associated metabolic problems is frequently
inadequate.56,57 While the least medically-toxic antipsychotics medication should
be used in an effort at primary prevention, it cannot be forgotten that the use of
clozapine, perhaps the wors offender with respect to

associated, metabolic

complications, is associated with the lowes risk of mortality in patients with

schizophrenia compared to no treatment or treatment with other antipsychotics. 58
Patients with SMI benefit behavioral interventions aimed to reduce weight, if
those services are offered.59 As smoking is a main cause of preventable mortality,
providing maximum support for smoking cessation is one of the most critical
health goals for all patient s with SMI who are smokers.

The interplay between medical and psychiatric health has led to a much
greater emphasis on providing better medical care for patients with SMI,
including the establishment of mental (or behavioral) health homes that aim to colate and integrate psychiatric and primary care services. 60,61 Patients with SMI can
responsible for aspects of their general medical and psychiatric treatment (chronic
disease self-management), and such approaches can empower patients and
improve outcomes.62-64
Reducing Substance Misuse
Alcohol and illicit drug use greatly complicate treatment efforts for
patients with SMI. Even low-grade use can reduce the efficacy of prescribed
treatment and should be monitored and addressed if present. Stabillity of housing
and social connections is often related to patients ability to engage in formal
substance use treatment, particularly if there is an addiction. Effective
pharmacological treatments for alcohol dependence exist (e.g, naltrexone,
acamprosate, and disulfiram), and modest evidence supports the use of naltrexone
and disulfiram in schizophrenia65 and nalxetrone in bipolar disorder.66,67 However,
general rates of prescriptions of anti-dipsomanic agents remain low for any
patient.68
Improving Quality of Life
Patients can benefit greatly if clinical factors associated with poor quality
of life are addressed, particularly depression and demoralization69 and medical
well-being (e.g, pain).70 SSRIs have shown some benefit for the treatment of the
subsyndromal depressive symptoms that are common in schizophrenia. 71 Qualityof-life considerations need to factor in the choice of pharmacotherapy, and
sometimes les aggresive, but better tolerated, medications with better efficacy.
Non-medical, recovery-driven approaches can restore hope and purpose through
the attainment of meaningful employment and relationships.
ONGOING CHALLENGES
In the US, community-based treatment has rightfully replaced institutions
as the primary setting for ongoing treatment and recovery. At the same time, an

under-funded mental health system complicates the delivery of services and

supports known to be effective. All to often, care for patients with SMI still
proceeds in a fragmented health care system with poor acces to truly integrated
and comprehensive services that provide timely medical, psychiatric and
substance use treatment. Moreover, instead of receiving psychiatric treatment in
the psychiatric treatent setting, patients have been transinstitutionalized into
penal system. Rudolf Virchow was

among the first modern psychians to

recognize the etiopathogenic role of environmental factors for the prognosis of

disease. Psychosocial factors, such as structural violence (e.g, lack of access to
treatment) more than biology determine the natural course of most illness 72 and
hinder better outcomes for patients with SMI. Untreated or delayed treatment of
psychosis damage lives as Liebermen and Fenton put it i an editorial regarding
the need for timely treatment of psychosis.73
Stigma is one mayor operative factor responsible for the current
inadequacy of funding and the structural separation between mental

health,

substance use treatment, and primary care. Stigma is also a fundamental cause nof
health inequality. Despite progress on paper (e.g, health insurance parity under
thhe federal Mental Health Parity and Addiction Equity Act), SMI remains a
highly stigmatized affliction. Meaningful societal inclusion of psychiatric ghettos
are easily created, even without state hospitals. Patients may become
institutionalized in the community if they feel their lives are effectively limited
to group home living and day program participation that is only interrupted by van
trips between thise two places. Frequently, not much is expected of patients, and
such low expectations breed poor results.
Globally, societies struggle to create legal frameworks that balance the
protection of society from dangerous patients with a respect for patient autonomy
that does not inadvertently neglect suffering. There is no single agreed-upon legal
framework for when involuntary treatment should be ordered or for whom it
might be most effetive in the long run, taking into account the patients apprasial of
the involuntary admission and corresponding view of the psychiatric
profession.74,75 Moreover, controlled trials have failed to show that involuntary
admissions can be reduced by means of interventions that are often advocated

(e.g, community treatment order as na precondition for hospital discharge or joint

crisis plans that were developed during a period of stability).76,77
Short of a cure, how to humanely and effectively care for patients with
SMI will remain a vexing issue with no one best solution other than recalling an
admonition ascribed to Senator Hubert Humphrey: The moral tes of government
is how it treats those who are in the dawn of life, the children, those who are in the
twilight of lfie,, the aged and those in the shadows of life, the sick, the needy and
the handicapped.

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