Course Treatment and Outcome of Severe and Persistent Mental Illnesses

Introduction 70 Course 72

Short-Term Course of These Diseases 72 The Experience of Hospitalization 73 Long-Term Course of These Diseases 73 Course of Mood Disorders 77 Do Rehabilitation Services Matter? 78

Not Just New England 79 Treatment 79

Biological (Somatic) Treatments 79

Efficacy of Antipsychotic Medication 79 Atypical or Second-Generation

Antipsychotic Medication 80 Reasons Medications Fail 81 Medication Side Effects 82 What Are the Best Antipsychotic

Medications? 83 Do Traditional versus Second-Generation Antipsychotics Have Different Therapeutic Effects? 84 Pharmacological Treatment of Bipolar

Disorder and Mania 85 Course of Bipolar Disorder When Taking

Lithium 86 Pharmacological Treatment of Major

Depressive Disorders 86 Does Antidepressant Medication Improve the Course and Outcome of Major Depression? 87

Future Possibilities 87 Medication Compliance 88 Role of Psychoeducation in Illness

Self-Management 91 Staff Competencies Required for Effective IMR 92 Psychosocial Treatments 93 Psychosocial Treatments of Bipolar

Disorder 95 Combined Treatment (Medication and Psychosocial) of Major Depression 95 Some Ineffective Treatments 95 Maria's Story 96 Understanding Course, Treatment, and Outcome: What the Staff and Consumers Don't Know Can Hurt Them! 97

Special Treatment Considerations with Dual

Diagnoses 99 Service for Persons with

Developmental Disabilities and Mental Illness 99 Summary 101 Class Exercise 102 References 102

An individual's experience of severe and persistent mental illness can be several months to many decades in length. The course of the illness is usually characterized by a significant risk of relapse and may include persistent symptoms. Psychiatric treatments, both pharmacological and psychosocial in nature, are intended to positively impact the course of mental illness by controlling, eliminating, and reducing symptoms and reducing the length, frequency, and severity of relapses. For schizophrenia and mood disorders, psychotropic medications are often the primary treatment. These medications, when properly prescribed and taken by the individual, often result in a less virulent course of the illness. Unfortunately, although many individuals experience a great deal of relief, the outcome is rarely a cure. Responsiveness to treatment may vary widely for individuals with the same diagnosis. There is also wide heterogeneity of outcomes among people with severe and persistent mental illness, ranging from those who deteriorate over time to individuals who have no symptoms at all and no relapses.

While these disorders require biological treatments, they also demand psychosocial interventions such as support and rehabilitation to promote the best possible outcomes. Longitudinal studies that tracked people with severe mental illness for more than 30 years have found that in the long run, most people who receive these services cope better, have decreasing symptoms, and function better in the community. Unfortunately, even those who are coping well may suffer occasional relapses. However, these relapses do not preclude other positive outcomes such as the attainment of living, learning, and working goals. Thus, in addition to the heterogeneity of outcomes between individuals, there is a multiplicity of outcomes for each individual. That is, over the course of many years of dealing with mental illness, one individual may experience numerous negative outcomes (e.g., persistence of symptoms, relapses) and positive outcomes (e.g., remission of symptoms and achievement of independent living goals).

This chapter will answer the following questions:

1. Does the functioning of people with severe and persistent mental illness deteriorate or improve over the long term?

2. What are the probable short-term and long-term outcomes for persons diagnosed with schizophrenic disorders or mood disorders?

3. If these illnesses are caused by biological factors, why are psychosocial treatments effective?

4. Can support and rehabilitation impact the course of severe and persistent mental illness and bring about positive outcomes?

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