Mental Illness Revisited

June 17th, 2005 by

We recently blogged a study in mental health that concluded that nearly half of all Americans will suffer from some form of mental illness during their lifetimes. Whenever this type of information is disseminated, it gives rise to inevitable skepticism. When the percentages are high (“nearly half of all Americans”), the numbers may lack credibility.
It turns out that the definition of mental illness is a subject of debate within the psychiatric profession itself. An article in the New York Times (registration required) by Benedict Carey discusses the fault lines within the psychiatric profession. Carey notes that “the boundary between mental illness and normal mental struggle has become a battle line dividing the profession into two viscerally opposed camps.”
On one side are the doctors who say that mental illness should be defined in broad enough terms to include relatively mild conditions, which they believe often lead to more severe problems later. On the other side are the doctors who want current definitions to be tightened, to ensure that resources are focused on the people who need them most. These latter doctors are concerned that when the definitions are too broad (as is perhaps the case in the recent study), the general public (and perhaps the occasional blogger) has a tendency to scoff at the findings.
Defining Mental Illness
There is a lot at stake here and as always, insurers are caught in the middle. The battle ground may well be the pending revision of the American Psychiatric Association (APA)’s diagnostic manual — the catalog of mental disorders on which treatment and the profession itself are based. The next edition is due out in 2010 — and right up until the printing deadline there will be debate about where to establish the cut-off points for clinical disease.
Diagnosing mental illness can be similar to working on certain types of lower back pain. In the absence of any objective findings, the doctor is limited to observations of behavior and the patients’ own answers to basic questions: how do you feel? How bad is it? What effect is it having on your life?
Ultimately, this comes down to the issue of severity: what effect does the condition have on an individual’s ability to function at home, in public and in the workplace? Magellan Health Services, a major provider of mental health insurance, has developed standardized tests to determine the degree of impact on someone’s life. They also have a report on “common warning signs,” which I would very much like to read. Unfortunately (and I caution you not read too much into this), the PDFs for this report appear to be inaccessible, at least at this time.
Mental Illness and the Workplace
Just as physical health impacts one’s ability to perform certain jobs safely, relative mental health can impact safety as well. This is an area where most employers rightfully fear to tread. On the one hand, the workplace may be a danger zone for people who are experiencing mental disorders. On the other hand, the workplace is part of the safety net for all of us — we often rely on the consistency and certainty of work to define ourselves and to stabilize our identities.
So when confronted with bizarre or unusual behavior, what should employers do? The Canadian Psychiatric Association has put together a useful brochure on “mental illness and work.” This document includes some basic guidance for employers in handling employees who may be suffering from mental illness. They recommend approaching employees with flexibility and compassion. As with any situation requiring accommodations, the answers often emerge from candid and confidential conversations with the workers themselves.
The Times article quotes a 48 year old business analyst who developed panic attacks to the point where he dreaded even small meetings with friendly coworkers. “It’s very bizarre; the only way I can describe the feeling is, Imagine walking down the street at dusk having someone put a gun in your face and threaten to kill you – having that absolute terror before a routine work meeting.”
It’s not hard to imagine that such a phobia would directly impact this person’s performance at work. Indeed, a typical employer would be likely to document the performance issues and eventually terminate him. Fortunately, this man’s wife had watched a therapist talk about social phobia on television, which led directly to his getting help. This is a case of a mental illness that gradually approaches and then passes the threshold where it impacts the individual’s ability to function.
It will be interesting to track the APA’s progress in revising the diagnostic manual. The final wording will directly impact how we perceive certain behaviors — and what behaviors will be considered “compensable” by insurers. Polls, studies and definitions aside, we may never be able to determine what percentage of Americans suffer from mental illness. But one thing is certain: the drama of untreated mental illness will play itself out in the narrow confines of families, in public spaces, and in workplaces across America.