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ABSTRACT Increasingly, mental health policies focus on "serious mental illness" (SMI). This trend is mostly unquestioned, but SMI policies have serious flaws that raise concerns about their effectiveness and desirability. One such flaw is the lack of consensus on how to define the population with SMI. This problem means that under various policies, groups identified as having SMI may be as much different as alike and may vary greatly in size. Another serious limitation is the lack of essential and accurate data on the SMI population. SMI policies are further complicated by unexamined conceptual issues-for example, why it is necessary to have policies in mental health services that discriminate on the basis of severity. Finally, the potential negative consequences of SMI policies, such as stigma effects, are rarely considered in their development. In this article I describe these problems and discuss the issues and challenges that they pose for effective mental health policies. I conclude that the desirability of many policies focused on serious mental illness are questionable, and I suggest types of questions that should be asked when such policies are considered.
For more than fifty years an element of mental health policy making has been concern with how such policies affect people with the most serious disorders, particularly their ability to access services and supports. Different constructs have emerged over time to conceptualize this part of the mental health population. In the 1970s these patients were most commonly discussed as those with "chronic mental illness." However, after complaints that the term had negative connotations, the construct of "severe and persistent mental illness" became preferred.1 Eventually, this construct fell out of favor in preference for "serious mental illness" (SMI), which is understood to encompass a broader range of conditions than either of the previous two constructs, including severe conditions that may be disabling but are not always chronic or persistent.2
There clearly is benefit from using the SMI construct to help understand the characteristics of people with the most serious mental disorders and how they are affected by mental health policies and practices. However, increasingly, the use of the construct has moved beyond research and planning and has been used as a basis of policy itself. Examples of policies that focus on SMI...