Disability and clinical course of severe mental illness

Abstract

Background:Social disability is a key outcome measure for severe mental illness, being a pivotal variable, that modulates the effectiveness of treatments and might be modified by the treatments themselves.Objectives:The aims of the studies presented were: 1) to determine changes overtime in symptoms and social disability in a 1 year treated prevalence cohort of subjects affected by psychosis vs. those affected by non psychotic disorder receiving community-based mental health care, and to explore 2) predictors of clinical and social outcome; 3) the effect of clinical course on disability and quality of life.Methods:Three hundred fifty four patients treated in the South-Verona CMHS were followed-up over 6 years (with assessments made at baseline, at 2 and 6 years) by using a set of standardised measures exploring psychopathology (BPRS), social disability (WHO-DAS) and quality of life (LQoLP). GLLAMM models were used to explore longitudinal predictors of clinical and social outcome. The effect of clinical course on disability was explored by consulting retrospectively the clinical records.Results:In psychotic patients relationships with partners were more frequently severely impaired, followed by dysfunction in the occupational and parental role. Longitudinal analyses displayed a clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are not fatally prone to a destiny of chronicity. Models explained 69% of the total variance for social disability. Predictors for disability were clearly differentiated from those for clinical status, but the two domains appeared entwined: the main clinical predictor of social disability was the negative component of psychotic symptoms (the higher negative symptoms, the lower social functioning) and higher disability predicted in turn a worsening of negative symptoms. Continuous course was associated with higher disability and lower quality of life.Conclusions:Psychopathology and disability are distinct outcome domains only partially overlapping, which do not directly co-vary overtime and are influenced, at least in part, by separate predictors susceptible to specific interventions. However, they are entwined in a vicious cycle leading overtime to a progressive reciprocal worsening with deleterious effect on patients' daily living and independence. Modern mental health services should be capable of shaping treatments to address these patients' multifaceted problems.