Epilogue Reconsidering Outcome Priorities for Serious Mental Illnesses
ROBERT B. ZIPURSKY
Mental illnesses are often assumed to be less treatable than medical illnesses, the corollary being that chronic illness and disability are more likely than remission and recovery. For the most severe forms of mental illness, such as schizophrenia, progressive clinical deterioration has been considered an intrinsic part of the illness for more than a century.1,2 The recent development of early intervention programs for psychotic disorders has provided new opportunities to re-examine this assumption and to ask key questions about potential outcomes. These questions include what outcomes are being achieved, what outcomes might be possible, and what are the determinants of these outcomes. These questions have been pursued with tremendous energy internationally and have contributed to the creation of a remarkably dynamic and creative field of early intervention for psychiatric disorders.3 As new approaches have evolved to optimize outcomes, it has become evident that a consensus does not exist about what outcomes are of greatest priority. One might have thought that the outcomes that are of most importance would be quite self-evident; this does not appear to be the case. On reflection, it should not be surprising that different outcomes may be of varying degrees of importance to patients, families, health professionals, and government. Characterizing priorities for outcomes from mental illness will likely be important for understanding why some outcomes are readily achieved and others remain elusive. It may also lead to newer and more creative approaches to achieving better outcomes.
The focus of early intervention efforts in adult psychiatry has been on schizophrenia and related psychotic disorders because these disorders have been a leading cause of disability worldwide and have resulted in enormous health care and social service costs. The discussion that follows relates most directly to what has been learned about schizophrenia as a result of research over the past 30 years but should also be informative for the study of early intervention for other mental disorders in the future.