“Serious” Mental Illness

DeeDee newI’ve seen references to “serious” mental illness here and there. What the heck does that mean? Even Google can’t give me a clear answer. A fantastic blog post by Kaitlin Bell Barnett pretty well says everything I would have said about this topic. Rats. Now I have to come up with something more.

A point I’d like to specifically highlight is that most of the time, this term is reserved for illnesses that involve mania or psychosis: schizophrenia, schizoaffective disorder, and bipolar disorder. The National Institute on Mental Health uses a broader definition:

  • A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)
  • Diagnosable currently or within the past year
  • Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
  • Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities

NAMI agrees, and includes several more conditions besides those that are generally understood to be serious. It’s only logical to argue that a DSM diagnosis indicates seriousness, since that’s often one of the diagnostic criteria. One of the key considerations is clearly the level of impairment, which is often measured by the Global Assessment of Functioning. Apparently 60 or lower is a rule of thumb used in some cases (though I’ve lost the link that said so.) Blue Cross Blue Shield of Illinois is very clear about what is considered serious and what is not, and I disagree with their categorization of at least a few of these conditions as non-serious. They also mis-classify ADD/ADHD as a (non-serious) mental illness instead of a developmental disorder.

Another important aspect was discussed by bipolar blogger Natasha Tracy, who is also quoted in the above-mentioned post: if you’re in severe pain due to mental illness, it’s serious. With this, I wholeheartedly agree. But there may still be some value in discriminating between persistently serious conditions and temporary serious conditions. Perhaps if you’re expected to need psychoactive medication your entire life, that might be considered more “serious” than a condition for which short-term medication or therapy-only approaches are appropriate. I really don’t know – it’s a very slippery slope.

If we use the criteria that lean on the GAF, then what? Looking at the details of the mGAF-R (PDF), it seems a bit subjective because all of these things are relative, just like everything else I report to mental health professionals. If a psychiatrist who only sees you for 15 minutes every month or three is making the evaluation, then it’s hard to argue validity to me. I’d want my therapist making this judgment instead.

Since no one has evaluated me with the GAF – to my knowledge, anyway – I’d probably score myself between 41 and 53, depending on when you ask. My level of impairment really varies with mood episodes and medications and about a million other factors, or so it seems. Before Lamictal, I was almost always in the 40’s. Even when I feel that my condition is fairly well controlled with medication, I periodically have moderate mood symptoms and/or problems in work functioning. The meds reduce the frequency and duration of episodes and tamp down the intensity a bit, but I’ve come to realize that bipolar disorder will always be there in the background.

Interestingly, hypomania shows up nowhere on the GAF. It’s only when you get to the Group D categories (in the 40’s) that mania is mentioned. I’d argue that hypomania can cause impairment as well, but perhaps that means that I’m actually manic and not just hypomanic after all. I haven’t yet been able to get a clear fix on that.

Regardless, I fall into the “seriously mentally ill” category. That’s not unexpected since bipolar disorder is consistently considered a serious mental illness, and as a result, my treatment needs will almost always be covered by insurance. Although I’m glad to know that my problems are taken seriously as a medical condition, I’m simultaneously amazed to realize that I was this ill for years and never knew it.

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15 thoughts on ““Serious” Mental Illness

  1. Thank you for the very nice link to my post, and by the way, I think this post is an excellent addition to an important conversation, especially the mention of the GAF and the link to the very arbitrary Blue Cross Blue Shield determination. How did they come up with that?!

    • Well, the BC/BS thing mentioned “legal” definitions somewhere, but my (quick) searching didn’t turn anything like that up. They might be going on something related to ADA or SSDI determinations, but that seems like a stretch to me.

      I’ve seen bloggers mention the GAF and wondered if I was getting substandard care because no one ever went over anything like that with me. I’ve seen no evidence of standards of care or best practices for managing serious mental illnesses (in the US) other than “treatment”, which can vary substantially.

      • Just an FYI, neither my former nor my current psychiatrist ever did any kind of GAF (I don’t actually even think that the state psychiatrist did it for my SSI determination), and both of them are excellent doctors who provide positively superlative care. Also, I underwent two different comprehensive consults with another doctor, who is the doctor Where I Live, as far as bipolar and other mood disorders are concerned. He also did not use the GAF. So while you may have been receiving substandard care, I don’t think you should use the lack of a GAF assessment as any type of criteria for deciding that.

    • Developmental disorders are those that occur during a child’s development – they can be either physiological or psychological. The degree to which ADHD is physiological versus psychological is debated, but it might be some of both. It’s considered a developmental disorder separate from learning disabilities.

      • I think I have a learning disability or perhaps a comprehension disability. I read about a women who had a similar situation with learning new things of a technical type nature but I didn’t write down the name of it. It’s so annoying but I think i was probably in denial about having a learning disability at that stage. I remember in a math’s class at my primary school that the teacher had my Mum in to the class after school to try and show her that no matter how she presented the information I couldn’t comprehend it. I really wish she’d picked up on it then and taken me to a early childhood expert.

  2. “Although I’m glad to know that my problems are taken seriously as a medical condition, I’m simultaneously amazed to realize that I was this ill for years and never knew it.”
    Agreed. To think I thought what I was experiencing was normal…out of control PMS, too much stress, mood swings up the ying yang…and that was normal? How did I do it? Only God knows.
    Thanks for this outstanding information!

  3. Interesting post. Some quick thoughts. In California to qualify for treatment paid for by Medi-Cal someone needs to have SMI meaning serious and persistent mental illness. The assumption here is that they will not get better without treatment and may need meds for the rest of their life. For Children we also are allowed to treat SED (Serous emotional disturbance) because an emotional problem can interfere with normal development. These are often referred to as “parity” diagnosis meaning things your insurance provider is willing to pay for. The specific DSM numbers that are SMI are mostly determined by whoever is paying for the treatment.
    GAF is about the overall level of functioning. We record both the current GAF and year ago GAF to see if the person is getting better or worse. The GAF in the DSM-4 is slightly different than the mGAF you linked to. Yes in practice it is VERY subjective and the number varies from clinician to clinician. Any one clinician should be more consistent in the number they give patients.
    You can be diagnosed with schizophrenia and on meds and still have a high GAF if you have a job,
    friends and like your life. You can have a condition that is neither serious nor persistent, but if you are thinking of suicide and have a plan and a time picked out, you are going to have a low GAF. In practice people with a GAF below 50 need help now. People with a GAF in the 60’s and above may be put on a waiting list. If you ever had a full assessment you were given a GAF as it is required in the five axis system in the DSM-4.
    Your GAF could fluctuate from week to week or even day to day. You diagnosis should not change very often.
    Remember also you could have diabetes and a cold, so you could receive a number of different diagnoses. There is a specific protocol for when we “stack up diagnosis” and when one diagnosis “trumps” or includes other diagnosis.
    The distinction between mania and hypomania is often a matter of “Clinician judgment.” It is used mainly to distinguish between Bipolar I and Bipolar II. If you have even had an episode of full mania looking for hypomania loses its significance.
    Major Depressive Disorder is also considered a SMI because of the high risk of suicide and other violence or self-harm. Something like ADHD may result in a low GAF if you can’t hold a job as a result but most insurance companies would not include it in the parity diagnosis. Most ADHD meds are prescribed by primary doctors not psychiatrists.
    The 10 or 15 minute time with the psychiatrist you mention should be a “med check” or med management. Before the psychiatrist writes the first prescription, most of the psychiatrists I know do an hour to two hour first session when they do a full 5 axis assessment and check medical history.
    Great post, keep up the good work.

    • Thanks for all the details, David!

      I think the GAF is even more confusing than I interpreted it to be – but your examples really help, because now I think I’d score higher than I expected! I haven’t had a proper full assessment – or at least, anything that resulted in information shared with me or a treatment plan – because I’ve had lousy psychiatrists. One of them might have done a GAF for me but was also the one who refused to tell me her diagnosis because I had to stop seeing her due to the expense. Professionalism? Yeah, not so much, in my experience…

      I need to learn more about the mania/hypomania line. Hypomania is fun (at first) but scares the pants off me because I know how much crazier it can get. I haven’t crossed some of the obvious lines but I’ve danced on them and maintained just enough of a grip on reality to avoid doing something disastrous.

  4. This is an interesting topic, and one that has never actually crossed my mind. That’s probably because after years of failed medication therapies, disastrous electroconvulsive therapy, failed therapeutic interventions, and the fact that I have been maintained on SSI for years now, it just never occurred to me to think that my mental illness could qualify as anything besides serious.

    I definitely agree that the Blue Cross/Blue Shield criteria is pretty crap. As for the GAF, well, for me it’s a bit murky. For most of the past year, consistently, and as recently as last month, I would have been neatly rated a 21 (due to criteria in the “Unique Item” section that I am not yet comfortable disclosing). There may actually have been times I would have rated as low as 8-10, but I’m not entirely clear on all the finer points, so I would have to ask my psychiatrist for clarification (he’s a good man who has been doing this for years and really knows his sh*t).

    As to where I would be rated now, I think it’s impossible to even accurately rate me using this methodology. So much of it depends on things like school or work – neither of which I am engaged in (at least not in the context that I imagine is intended) – and the subjectivity comes highly into play for me in other areas. But I won’t bore you with it all. :)

    Thanks for the informative write-up, I always like to learn about things I hadn’t researched before!

    • Funny what we do or don’t take for granted, isn’t it?

      I found the GAF surprisingly opaque for something that’s used for that sort of judgment. I understand the need for vagueness as well, but the fact that I can’t confidently figure out where I would fit on that scale is a little alarming. The fact that it’s so highly variable is also a bit disturbing to me, though I think some of that is the nature of the illness. And then there’s the question of how realistic I’m being. Yes, I’m getting work done – at what cost? How long is it taking me compared to how long it might take if I were at a “normal” level of functioning? The conditions under which I can do my work require absolute solitude and undisturbed days; how functional is that, really?

      Anyway, I agree – if it were used in making determinations of eligibility for insurance or services, I see major problems with this kind of tool due to the subjectivity. It would take a whole lot of examples for me to feel comfortable trying to judge what a GAF should be for me, and I know my own functionality pretty well.

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