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Functional Outcome and Psychotic Illnesses
Spring 1998
The VISN 22 Mental Illness Research Education and Clinical Center (MIRECC) is addressing one of the most compelling dilemmas in Mental Health: Medical research has made substantial progress in understanding and treating the severe psychotic symptoms that can occur in schizophrenia, schizoaffective illness, bipolar disorder, and major depressive disorder and yet very little progress has been made in understanding the factors that determine whether patients with these disorders can return to work, school, or their prior role in the family and community. This relatively poor understanding of the biological underpinnings of what is often referred to as "functional outcome" helps explain the relative ineffectiveness of our treatments. In this column I plan to describe the severity of functional impairments in psychotic illnesses. In future columns, I will describe the approaches of MIRECC investigators to understanding and treating individuals with these disorders.
Schizophrenia, the most debilitating of the psychotic mental illnesses, is among the most costly illnesses to society and the VA. For schizophrenia alone, the costs of clinical care, rehabilitation and support services exceed the cost of all cancers combined. Although many patients with schizophrenia are employed and well educated, only about 10% of individuals with schizophrenia function at the same level as the average person in the community. Studies indicate that the poor social and vocational outcome in schizophrenia is not related to the severity of symptoms such as hallucinations and delusions, the so-called positive or psychotic symptoms. Rather, individuals who have a poor functional outcome tend to be those who have disturbances in negative symptoms which include impaired motivation and lack of emotional expressiveness or cognitive symptoms which include impairments in attention, concentration, and memory. These observations indicate that to improve our understanding of functional outcome it will be important to focus on understanding negative and cognitive symptoms.
Although functional outcome is usually better in bipolar disorder than schizophrenia, bipolar patients can suffer from similar impairments. One investigator followed patients with bipolar disorder for five years and found that the bipolar cohort showed significant deterioration in all domains compared to a control group. Forty per cent of the bipolar patients were unemployed at the end of the five year period. Another research group found that 80% of bipolar patients they monitored were symptoms free after 6 months, but only 21% were employable at preepisode levels. Other studies have found similar results.
The MIRECC will approach the issue of functional outcome in these illnesses through a program that includes research, education, and clinical care. The research program will span areas from basic research to clinical research to services research. The basic research program will focus on the biology of cognition and motivation; the clinical program will study promising medications and psychosocial research strategies for improving functional outcome; the services research program will focus on how the organization of clinical services can facilitate or interfere with delivering the best clinical treatments to patients with these disorders. I will present details of these research in future columns.
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