Pathways of recovery: preventing further episodes of mental illness (monograph)

Likelihood of preventing relapse

Page last updated: 2006

It is only recently that the possibility of preventing mental illness has gained credibility (Monograph 2000). As already noted, there are three possible scenarios following the initial onset of mental illness: no further episodes of mental illness; occasional recurrent episodes of mental illness; and chronic mental illness with repeated episodes.

Prior to the 1990s, which has been termed the 'decade of recovery', the third scenario was commonly held to be the inevitable outcome of a diagnosis of mental illness. This view was assumed by most clinicians and presented to people who experienced an episode of mental illness and their families as a fact that needed to be accepted. In the 1990s, two bodies of knowledge converged to change this view (Anthony 2000). The first was the writings of people seriously affected by mental illness. These compelling personal accounts provided anecdotal evidence of the many and varied individual pathways of recovery (eg, Anonymous 1989, Deegan 1988, Leete 1989).2

The second was examination of outcome studies of people with mental illness. Harding and colleagues reviewed long-term studies of outcome, which showed that people with severe mental illnesses were, in fact, recovering (Harding et al 1987, Harding & Zahniser 1994). It was clear that the prognosis for people diagnosed with mental illness was much more favourable than previously thought (Anthony 2000).

Outcome data usually come from investigations of the duration and restitution of mental illness in small samples of referred patients (Pevalin & Goldberg 2003), and are, therefore, subject to many methodological problems. Nevertheless, the evidence is convincing enough to argue that the majority of people diagnosed with a mental illness can be expected to improve significantly or fully recover.

Some of the most compelling evidence comes from the studies by Harding and colleagues. For example, Harding and Zahniser compared the results of five long-term outcome studies of people diagnosed with schizophrenia (see Table 1). They concluded that:

"These studies have consistently found that half to two thirds of patients significantly improved or recovered, including cohorts of very chronic cases. The universal criteria for recovery have been defined as no signs or symptoms of any mental illness, no current medications, working, relating well to family and friends, integrated into the community, and behaving in such as way as to not be able to detect having ever been hospitalized for any kind of psychiatric problem." (Harding & Zahniser 1994 p140)
Top of pageThe evidence is even more positive for people diagnosed with major depression. Data from the NIMH Collaborative Depression Study, a prospective long-term naturalistic study of mood disorders in 550 people seeking treatment at five different medical centres in the United States, reveal that the recovery rate after two years was about 80%, and increased to 94% after 15 years (Keller & Boland 1998). Nevertheless, relapse was common: after two years of prospective follow-up, 25-40% of people experienced a second episode of depression, and after 15 years, 87% had experienced a relapse. After a severe episode of depression, persistent sub-syndromal levels of depression are common, and these tend to fluctuate with full episodes of depression (Kennedy, Abbott & Paykel 2004).

Growing awareness that the majority of people diagnosed with mental illness will achieve a significant improvement or full recovery greatly enhances hope for people diagnosed with mental illness, and provides strong support for investing in relapse prevention.

Table 1. Outcomes from long-term follow-up studies of persons diagnosed with schizophrenia

StudySample SizeAverage length (years)Percent recovered or significantly improved
Bleuler (1972a,b) Burghölzli, Zurich
208
23
53-68%
Huber et al (1979) Bonn Studies
502
22
57%
Ciompi & Müller (1976) Lausanne
289
37
53%
Tsuang et al (1979) Iowa 500
186
35
46%
Harding et al (1987a,b) Vermont
118
32
62-68%

Source: Harding, Zubin & Strauss 1992 p29

Footnotes

2 For an anthology of Australian recovery stories, see Inner East Mental Health Services Association Inc – Terra Firma (2003) Recovery Paths. An Anthology of Personal Journeys of Hope. Terra Firma, Box Hill, Victoria.