Outcomes at the countryregional level

In epidemiology, the classic outcome measures at the population level are mortality and morbidity rates, but while these have also been used in epidemiological psychiatry as outcome measures, the use of such indicators taken from general medicine for psychiatry needs careful translation for the following reasons. First, the conditions under investigation in cardiology or oncology have a direct causal association with death, while in psychiatry the established higher mortality rates (! IP are indirectly associated with mental illness, most often through suicide or risks from patients' lifestyles. Second, morbidity indicators used as outcome measures in mental health need to be seen in a modest context; so far, psychiatry has not been able to effect primary prevention for any form of severe mental illness.

Mental health services are almost entirely concerned with secondary prevention (reducing symptom relapse) and tertiary prevention (reducing the suffering consequent upon symptoms). In this case, the relevant outcomes in the mental health field can be subsumed within the headings of impairment (primary symptoms), disability (consequent reduced ability to perform specific skills), and handicap (limited social role performance), as formalized by the World Health Organization International Classification of Impairments, Disabilities and Handicaps.'l22 Alternatively, outcomes may deal with other consequences of health services provision, such as service satisfaction or impact on caregivers.

Directly in relation to the population level, a frequently used outcome measure is suicide rate (see cell 1C in Table 1). Rates of homelessness among mentally ill people (or rates of mental illness among the homeless) can also be used as an outcome indicator of the effectiveness of mental illness policies at the national level. In practice, however, we are unaware of any such studies at this level, and most such data are only relevant to the local level. (l3,l4> The same applies to the inappropriate placement in prison of those who would be better treated in mental health facilities. ^l6)

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