Why prognoses in psychiatry are unpredictable
Mental health problems do not follow a fixed, predictable path the way physical illnesses do. That makes their prognosis very complex and unpredictable.
Problems such as depression, psychosis, anxiety or addiction do not develop in fixed stages. Where the process in an illness such as cancer is progressive, the condition of someone with mental health problems can be erratic. Even in situations that seem hopeless, such as severe suicidal thoughts or tormenting hallucinations, recovery can occur at unexpected moments. In mental health care it is not unusual for someone to turn a corner after years of severe complaints. This unpredictability means that the accuracy of prognoses in psychiatry is only around 20%. A sharp contrast with the predictive power of disciplines such as oncology or cardiology.
The misunderstanding of linear recovery
A big difference between physical and mental conditions is that recovery in mental health care does not always mean that symptoms disappear. In medicine recovery is often about eliminating the illness: the tumour has to go, the infection has to be fought, the heart rhythm has to be stabilised. In psychiatry it works differently. A person can keep struggling with voices or anxiety, for example, and still learn to deal with these experiences in a healthier way. Recovery therefore often comes with a shift in the relationship to the symptoms. Someone can learn no longer to be afraid of the voices they hear, or find a way to handle their fears better. This is a form of recovery that goes much further than merely ‘removing’ symptoms.
Personal recovery: reinventing yourself
Another crucial aspect of recovery in psychiatry is that it is not only about medical treatment of symptoms. Many people who have had mental health problems describe their recovery as a process of reinventing themselves. This can mean redefining their identity and their goals in life. While the old life may no longer seem within reach, a new view of what is still possible can lead to a meaningful and satisfying life. This ‘personal recovery’ offers people the possibility of living with their susceptibility and talents, without having to be fully ‘cured’.
The limited biomedical model
The biomedical model in psychiatry often puts too much emphasis on medical interventions, such as medication or electroconvulsive therapy (ECT), as the solution for mental health problems. These treatments can play a part, but they are not always enough and not always what people need. The more severe the condition from a medical point of view, the more help people need with bearing their experiences and with the existential process of reinventing themselves. And these are the things you learn less in mental health care and more in recovery colleges and peer-run centres.
What is often overlooked is that the people with the most severe complaints benefit from working on their mental resilience, changing their relationship to their symptoms and developing new goals and meaning in their life. A purely medical perspective falls short here, because it does not cover the complexity and many-sidedness of mental recovery.
Conclusion: uncertainty and unpredictability as reality
In mental health care the future of a person cannot be predicted. This asks for a different approach from that in physical medicine. A medical model often starts from progressive stages and the removal of symptoms. Recovery in psychiatry is more about learning to bear and deal with mental challenges, and about finding resilience and new meaning in life. It is important to acknowledge this difference in order to do justice to the particular nature of mental distress and recovery. Psychiatry requires an open attitude towards unpredictability, and in that it also offers hope. Even in situations that at first sight seem hopeless from a medical perspective.
Read more: What is recovery?.
Prof. dr. Jim van Os, Chair Division Neuroscience, Utrecht University Medical Centre. Jim works at the interface of ‘hard’ brain science, health services research, art and subjective experiences of people with ‘lived experience’ in mental healthcare.
Jim has been appearing on the Thomson-Reuter Web of Science list of ‘most influential scientific minds of our time’ since 2014. In 2014 he published his book ‘Beyond DSM-5‘, and in 2016 the book ‘Good Mental Health Care’. In 2026 he published 'Wat psychisch lijden is'.
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Blogs by Jim van Os can be read here
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