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RESEARCH WEEKLY: Varying Policy Definitions of Serious Mental Illness
By Hope Parker
(January 18, 2023) There is significant variation among policy definitions of serious mental illness in the United States, according to new research, which indicates that researchers, policymakers and clinicians may have different understandings of what constitutes serious mental illness from one location to another.
Researchers at Columbia University and Adelphi University analyzed the formal policy definitions of serious mental illness, severe mental illness and SMI in 56 US States, Districts and Territories. Their analysis, published in Community Mental Health Journal, found that there are substantial differences in severe mental illness policy definitions and eligibility criteria between localities in the United States, with up to 10 states and territories not having any formal definition at all. Creating a common definition of severe mental illness is crucial for reliability in research, clinical services and public policy.
Study details
Data was collected between October 2020 and May 2021 by reviewing governmental websites and publicly available legislative administrative codes for all 50 states, Puerto Rico, U.S. Virgin Islands, Guam, Northern Marina Islands, American Samoa and the District of Columbia. If no definition could be found online or in legislation, a researcher attempted to contact department of health officials and/or legislative liaisons. Researchers chose to include definitions of both serious and severe mental illness in this study so that they were able to include as many definitions of “SMI” as possible.
Researchers then analyzed these definitions by examining their general characteristics, such as where the definition originated and specific eligibility characteristics, such as functional impairment criteria or age requirements.
For each definition, two researchers then independently determined how many definitions were available for each locality, where each definition could be found within existing legislation and if definitions were created by the locality or taken from another agency, such as the Substance Abuse and Mental Health Services Administration.
Researchers also inspected the eligibility requirements of the serious mental illness definitions, such as if there were restrictions on age, if they require evidence of functional impairment, previous use of mental health services, symptom duration, eligible psychiatric diagnoses or specified exclusionary diagnoses.
Study results
Formal definitions were able to be collected for 46 states, territories and districts. Four localities had no formal definition of serious or severe mental illness, and six locations did not have any publicly available definition of serious or severe mental illness, nor did any official respond to researchers’ requests.
- 32 definitions of SMI were found within state legislation
- 18 localities used pre-existing SMI definitions
- Four states used the Substance Abuse and Mental Health Administration’s definition of serious mental illness: “someone over 18 having (within the past year) a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities” (SAMHSA, 2022)
- 10 states provided more than one definition for SMI
- Nine states used SMI definitions to determine which individuals are eligible for specific mental health services
SMI eligibility criteria
The definitions had significant differences related to what was and was not required for an individual to be considered to have a serious mental illness:
- 38 states required functional impairment or disability to be present in their definition of SMI
- 22 states included age requirements
- 22 states included the prior use of mental health services in their definition
- 12 states included prior psychiatric hospitalization in their definition
- 23 states had a symptom duration requirement, such as requiring symptoms to be present for at least two years
- 23 definitions had criteria that specified symptom recency, meaning individuals must have experienced symptoms within a certain time period (e.g., within the last two years)
- 34 state and territory definitions stated any mental health condition could fit the criteria
- 26 states specified diagnoses that could count as SMI in their definition, such as schizophrenia, schizophreniform disorder, schizoaffective disorder delusional disorder, and psychotic disorder not otherwise specified
- 18 states included diagnostic eligibility exclusions in their definition
Implications
Many states have extreme differences in how they define serious mental illness, with some states even using more than one definition in legislation. This makes it difficult to craft effective public policy to address the unique needs of this population, according to the study authors. It also complicates service funding and allocation, as a lack of a standardized definition of serious or severe mental illness may impact grant eligibility.
Additionally, due to differences in eligibility criteria within SMI definitions, some individuals may qualify as having SMI in some locations but not others, which could affect which services are accessible to them. Only nine of the 46 localities had definitions that were intended to be used as a guide for clinical decision-making, despite prior claims that these definitions were created with practical utility in mind.
To better target this population in public policy, the study authors suggest the development of a standardized definition of SMI that can be used across states, territories, districts and other agencies within the U.S. is needed. The Office of Research and Public Affairs made that same recommendation in our 2017 report, A Crisis in Search of Data.
References
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Gonzales, L., Kanani, A., & Pereyra, A. (2022, September). Policy Definitions for “Serious Mental Illness” Across 56 United States, Districts and Territories. Community Mental Health Journal, 1-5.
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Substance Abuse and Mental Health Services Administration (2022, April). Mental health and substance use disorders. https://www.samhsa.gov/fnd-help/disorders
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