Author: John J. Spollen, III, MD
Medscape Psychiatry & Mental Health 8(1), 2003. © 2003 Medscape

The term "serious and persistent mental illness," or SPMI, is the currently accepted term for a variety of mental health problems that lead to tremendous disability. Although commonly associated with the illness schizophrenia, the severely and persistently mentally ill include people with a variety of psychiatric diagnoses. More than just a difference of diagnoses, there is a difference in culture when people speak of SPMI. The concept of SPMI presupposes an understanding that it is about a population of severely ill people and not about a DSM diagnosis, that it should include multidisciplinary treatment rather than just a physician, that a biosocial rather than a purely medical approach is often used, and that functional outcomes, especially social and occupational, are often more important than symptomatic outcomes.

 

The term "serious and persistent mental illness," or "seriously and persistently mentally ill," grew out of the term "chronically mentally ill." Chronically mentally ill, or CMI, was a term used to identify the patients who lived in state hospitals or other long-term institutions. With the passage of Kennedy's Community Mental Health Centers Act in 1963, the deinstitutionalization, or "dehospitalization,"[1] and the advent of widespread use of antipsychotic medications, care for CMI patients moved from institutional settings to community settings. Also, with successful treatment, some patients with CMI no longer had a "chronic" course of their illness. It also seemed to some that the term "chronically mentally ill" was a pessimistic and, possibly, pejorative term. Over time, the use of "severely mentally ill" or "severely and persistently mentally ill" became the accepted term for such patients.

 

But who are these patients? As psychiatrists who are used to diagnosing people with a standardized DSM method, how does one identify a patient who is "severely and persistently mentally ill"? In fact, there have been multiple definitions over the years leading to vastly different prevalence rates and confusion about which services to provide to which patient. One study found prevalence rates of SPMI between 4% and 88% of the population of adult patients treated at community mental health centers in Philadelphia, depending upon which definition was used.[2] However, the most consistent definitions of SPMI include a diagnosis of nonorganic psychosis, functional disability in areas of social and occupational functioning, and a prolonged illness and long-term treatment. It includes many patients with schizophrenia, but also people with bipolar disorder, severe major depression, and, in some less frequently used definitions of SPMI, substance use and personality disorders.

 

The treatment of the SPMI of course includes medications, but it also includes a variety of psychosocial modalities, usually with a strong focus on rehabilitation, and services available to both mental health consumers and families. Assertive community treatment, known as ACT, is the most known and accepted psychosocial treatment program designed for an SPMI population.[3] ACT grew out of the Program for Assertive Community Treatment, or PACT, model designed by Test and Stein as a response to the "revolving door" of repeated hospitalizations for the severely and persistently mentally ill in the early 1970s. With much research over the next 2 decades, ACT has become a standard model for comprehensive treatment of people with SPMI and is strongly lobbied for by the National Alliance for the Mentally Ill (NAMI) and others on a state and national level as a "best practice" form of treatment. The basic tenets of ACT include high-intensity community-based case management services with a low client-provider ratio, with various forms of direct assistance provided including medications, basic needs such as housing, food, and clothing, training in basic living skills, family and social support network psychoeducation, and vocational support. With the significant level of disability and functional impairment for many people with SPMI, the skills taught by ACT clinicians often start with such basic living skills such as how to navigate public transportation, how to shop for and prepare food, and how to access emergency services. The desired outcomes include not only reduced symptomatology and hospitalization but also improved quality of life and functioning in the areas of activities of daily living, social relations, and employment.

Another version of psychosocial rehabilitation is "Clubhouses," which grew out of the acclaimed Fountain House Clubhouse that began in New York City in the 1940s. Clubhouses are run for and primarily by mental health consumers and provide a safe and inviting meeting area with various services including socialization, housing assistance, and job placement services. While the original focus of ACT was from a provider perspective, Clubhouses were originally designed as a self-help organization for people with mental illness and continue to have a "member" rather than "patient" or even "provider" focus. An organization that works to coordinate and disseminate the model of Clubhouses is called the International Center for Clubhouse Development (http://www.iccd.org/default.asp).

 

In addition to large programs like ACT and Clubhouses, there are several published psychosocial rehabilitation texts that can be used by any provider treating people with SPMI. One of the better known is the well-known series of "modules" developed by Dr. Robert Liberman of UCLA (http://www.psychrehab.com/). The 9 modules focus on various aspects of the life with mental illness including managing symptoms and medications, interpersonal relationships and sexuality, leisure time and vocational activities, and substance abuse. The modules are usually taught in a small group format and have 4-9 specific skills that are taught with easily understood "learning activities."

With the impact of SPMI often affecting family, family support organizations and services are of great benefit. The most widely known is, of course, the aforementioned National Alliance for the Mentally Ill (http://www.nami.org/), or NAMI. NAMI is most known for its efforts as a support organization for families of people with SPMI. Among other important activities, NAMI offers a free 12-week Family-to-Family Education Program that is run by and for families. A full assessment of a patient with SPMI is often not complete without a referral for family to a local NAMI chapter.

 

As the value of employment for people with SPMI is measured not only in dollars and cents but also in self-esteem and quality of life, specific vocational rehabilitation is fast becoming an expected component of comprehensive treatment. A paradigm shift in vocational rehabilitation training for people with SPMI has occurred from the traditional "train then place" model to "place then train." Through supported employment, with on-site job "coaches" providing on-the-job training, people with SPMI can find and keep real jobs that most people, possibly including their own mental health providers, would not have felt possible. While the resources needed for this are often significant, the improvements in medications and various forms of case management on more traditional outcomes, such as symptomatology and hospitalization, have led to a focus on vocational and social outcomes, which have a stronger association with quality of life than more traditional "provider centered" outcomes.

 

For contemporary psychiatry, deeply rooted in biological theories of mental illness, the focus on working with people with serious and persistent mental illness is often much broader than straightforward medication management. To maximize functioning in a group of patients with SPMI, one must include not only best practices of modern psychopharmacology but also consider psychosocial rehabilitation, social support systems, available community resources, housing, and jobs. This section of Medscape Psychiatry hopes to provide mental health practitioners with the most current advances in treatment for people with severe and persistent mental illness including medications, psychotherapeutic interventions, as well as psychosocial and vocational rehabilitation. With an understanding of the vast array of tools now available for comprehensive treatment for SPMI, mental health practitioners can now offer much more than we could in the past.

References

 

1. Sharfstein S. Whatever happened to community mental health? Psychiatr Serv. 2000;51:616-620.
2. Schinnar A, Rothbard A, Kanter R, Jung Y. An empirical literature review of definitions of severe and persistent mental illness. Am J Psychiatry. 1990;147:1602-1608. Abstract
3. Spollen J, Meissler N, Santos A. Assertive community treatment. J Pract Psychiatry Behav Health. 1998;4:102-109.

John J. Spollen, III, MD, Assistant Professor, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Chief Mental Health Clinic, Central Arkansas Veterans Health System, Little Rock, Arkansas