Introduction

Chronic disability is a common feature of serious mental illness. Its relationship with psychopathology, particularly in terms of the nature and gravity of symptoms as assessed with the aid of diagnostic interviews and classified with systems like ICD-9 or DSM-III, has not yet been adequately established.

The ability to assess precisely the nature and consequences of chronic disability is becoming more urgent because of the trend towards avoiding long-term hospitalization. In a recent longitudinal investigation in Groningen, under the umbrella of the ‘WHO Collaborative Study on the Assessment and Reduction of Psychiatric Disability’ (Jablensky, Schwarz & Tomov, 1980) we followed a group of people over a period of 3 years. This comprised patients who, for the first time in their lives, manifested symptoms of non-affective functional psychosis (Wiersma et al., 1984b). It appeared that those with non-remitting or frequently recurring psychosis had, on average, spent less than 40% of their time in hospital. This was, in fact, somewhat less than people with a few limited psychotic episodes. In Fig. 1, each dot represents a patient in one of the subgroups with a particular course of psychosis during the first 3 years after the onset of the illness. The solid line connects the average percentage of time spent in hospital by the various subgroups. The broken line represents the same for any type of care. To give an example, the figure shows that nine patients in the two categories with the worst course (IVa and IVb) spent less than 20% of the period in hospital. This could be considered a satisfactory situation, but it was also found that the course taken by their disability was anything but favourable. The development of social disability did not parallel that of symptomatology. For the same subgroups, Fig. 2 illustrates the manner in which the disability developed over 3 years. Disability was measured using the Disability Assessment Schedule (Jablensky et al., 1980) and counted as the sum of the scores on the individual sections. In subgroup Ib. the deterioration of functioning, despite the complete remission of symptoms after the psychotic episodes, is remarkable.

These findings stress the need for an assessment of disability independent from that of psychopathology in order to direct social rehabilitation, particularly for people suffering from chronic psychosis (though not limited to that group).