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Serious mental illness and common mental health problems

A further distinction between different types of mental disorder is made with reference to ‘serious mental illness’ (SMI) and ‘common mental health problems’. Current mental health policy and practice is influenced significantly by the concept of SMI, the origins of which are many, but we draw attention to two predominant influences from the last decade. In 1990, White published the third quinquennial national survey of community psychiatric nursing.

A key finding was that 80 per cent of people with schizophrenia in England had never been on the caseload of a mental health nurse working in the community. Community psychiatric nurses (CPNs) had tended instead towards providing primary care based liaison services through which they were more likely to encounter patients with neurotic rather than psychotic symptoms. Alongside this increasing awareness of CPN activity the British media reported a number of high-profile homicides committed by people with a mental illness, which they argued demonstrated the failure of community care. Further, it followed that communities were now at risk from those with serious mental illness. The public concern that such reports generated was allayed by the Department of Health who began to target services towards people with SMI.

Thus, the Health of the Nation: Key Area Handbook  identified those with SMI to be the priority target group for services, although it acknowledged that defining this group was problematic. Similarly, the Mental Health Nursing Review Team  recommended that ‘… the essential focus for the work of mental health nurses lies in working with people with serious or enduring mental illness in secondary and tertiary care …’. Early attempts to differentiate SMI from common mental health problems relied heavily on the presence of a psychotic diagnosis as a marker for SMI, for example, McLean and Leibowitz and Patmore and Weaver. This position has essentially remained the same so that SMI is now synonymous with ‘psychoses’ and common mental health problems with ‘neuroses’. We make two brief observations regarding these new labels that have entered psychiatric parlance in the last decade. First, they are borne of social fears often fuelled by an ill-informed media. Second, were you (or us) to experience depression to the extent that suicide became a convincing option for you, but you had no psychotic symptomatology, your condition, following McLean and Leibowitz (1989) and Patmore and Weaver, would be considered a common mental health problem rather than a serious one.

While we might understand the basis for these labels their utility in practice is questionable. A nursing profession that sides entirely with the concept of serious mental illness, and its association with psychosis, is narrowing its professional repertoire. Perhaps more importantly, it is overlooking other subgroups within the adult population that will be marginalized by such a narrow definition of SMI.

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