One-year outcome of schizophrenic patients--the interaction of chronicity and neuroleptic treatment

In an ongoing prospective investigation of the course and outcome of schizophrenia, the global functioning (employment, social contacts, symptoms) and rehospitalization rate of 72 patients were assessed one year after clinical discharge. With regard to chronicity of illness, the global outcome was better for first admissions than for multiple admissions. On controlling the patients' functioning one year before index admission, this difference did not hold true. Hence, there must be difference in the functioning of the two groups which dates back a rather long time. However, multiple admissions showed an actual downward trend in their work functioning (p less than 0.05). Rehospitalization rates of the two groups did not differ significantly (33% for first admissions versus 40% for multiple admissions). Evaluation of differences in drug-taking behavior revealed that patients with better global functioning tended to take their neuroleptics not as regularly as prescribed. Whereas for good functioning first admissions, taking into account, their better spontaneous course (rehospitalization rate 27%), an intermittent neuroleptic strategy may be in order, for multiple admissions the reversal seems to be true (rehospitalization rate for compliant patients 27%, for non-compliant patients 73%, p less than 0.01). However, a small group of good functioning multiple admissions did not have to be rehospitalized in spite of non-compliance, whereas the patients with the poorest function relapsed despite their compliance. We conclude that, whereas for first admissions long-term neuroleptic medication may not be generally indicated on account of their prognostic heterogeneity most of the multiple admissions will profit by this therapeutic strategy in respect of rehospitalization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of treatment course on the success of psychopharmacotherapy]

Psychiatric illness course is not characterized by total regularity. More often there is marked individual variability. This is an obstacle to making a valid prognosis and applying broadly based indication rules. Still today predictors of illness course as well as indication criteria for treatment are little elaborate and often faile in the individual case. The most reliable instrument for planning and assessing psychiatric treatment is the treatment course itself. The therapist as a participating observer can more easily check tendencies of illness course and adapt therapeutic strategies. Characteristics of treatment course in guiding further treatment are examplified by means of neuroleptic treatment in the acute and maintenance phase of schizophrenic psychoses.

Prognosis of the course of schizophrenic psychoses compared to other psychiatric illnesses. Catamnestic treatment and outcome 1 year after discharge

In a prospectively designed study of the course of illness of 161 hospitalized psychiatric patients, data regarding outcome could be obtained for 93% 1 year after clinic discharge. It was possible to reexamine 67% of the patients by means of direct interviews. No significant differences appeared in the comparison of the course of illness outcomes (symptoms, rehospitalization, occupation and social contacts) of patients with schizophrenic psychoses, affective psychoses, neuroses or a group of mixed other diagnoses (predominantly alcohol dependency). For the group of neuroses there was a particularly striking discrepancy between the self- and the observer-ratings at the time of discharge from inpatient index-treatment. From this finding and from the comparatively more intense prominence of depressive symptoms at the time of follow-up, one can presume that there has been insufficient after-care treatment of this patient group considering the recorded treatment data. This seems to hold true for the group of alcohol dependents as well. In contrast, the after-care treatment of patients with affective and schizophrenic psychoses seems more likely to be ensured today. Despite this, however, for the latter the close link between the rate of relapse and the rate of rehospitalization can apparently scarcely be influenced.

Prediction of "natural" course, relapse and prophylactic response in schizophrenic patients

Three problems in the prediction of the long-term outcome of schizophrenia are illustrated by the results of three separate studies: The limitations of the possibility of generalizing results, the limits being due to the given historical and sociocultural settings. This determines the results of research. The relationships between different types of predictors and targets. The disease-related specificity of predictors. A prospective 1-year follow-up study comparing 100 schizophrenic patients in a rural region with 200 schizophrenic patients in an urban region shows regional differences in outcome criteria, such as rate of hospitalization. The prognostic significance of the various predictors is also different in the two regions. A follow-up study of 70 schizophrenic patients, who were continuously treated with neuroleptic drugs in our outpatient clinic after hospital discharge for an average of 14 years, shows a relatively good outcome. Several outcome dimensions (rehospitalization rate, symptoms, social and work adjustment, self-ratings) are partly mutually independent. The various outcome dimensions are predicted by different predictor patterns. A prospective follow-up study of 86 schizophrenic patients compared with 75 patients with other psychiatric diagnoses confirms the finding of the partly low intercorrelations of the different outcome criteria. The study additionally shows that the predictors of some outcome dimensions, such as work adjustment, are non-specific in respect of diagnosis.

[Predictors of the course of schizophrenic diseases under neuroleptic long-term medication (author's transl)]

70 schizophrenic outpatients have been treated continuously after index hospital discharge with neuroleptic drugs for an average of 14.3 years. In predicting their outcome in several dimensions (rehospitalization rate, symptoms, social and work adjustment, self ratings) differential predictor patterns could be confirmed, at most accounting for 65% of the outcome variance. In part work adjustment at follow-up cold be predicted by premorbid social and sexual adjustment as well as by working capability at index discharge. The most powerful predictor for the number of social relations was the former frequency of social contacts. Rehospitalization was related to higher neuroleptic equivalence dose at index discharge among other predictors, whereas presence of symptoms could be predicted e.g. by formerly longer hospital stays. Although at the beginning of the treatment our sample was classified as "process schizophrenic" on "classic" prognostic scales, 40-60% of our cases had a relative good outcome. This results and the considerable decrease of the rehospitalization rate from 0.57 before treatment to 0.11 during treatment stand for a clear treatment related improvement of the spontaneous prognosis. The partly mutually independence of the outcome criteria and predictor patterns underlines the importance of multiaxial diagnosis.

[On the prognostic value of the 1-h level in the glucose tolerance test. (Five year follow-up with long-term hospitalised psychiatric patients) (author's transl)]

In 922 long-term hospitalised psychiatric patients the glucose tolerance war examined by 1-h level after oral glucose during a five year follow-up study on cardio-vascular risk factors. We were unable to determine the future development of metabolism with reference to normal findings of the test, borderlines levels ans positively impaired glucose tolerance. But it was to be seen than depending on increasing basic levels the tendency towards a decrease in glucose tolerance increased too. As far as prognosis is concerned, a turning-point for the further development either towards a return to normal or a manifest diabetes seems to be at 180 mg% after 1 h. Above this level, the probability to develop manifest diabetes respectively a higher degree of impaired tolerance has become within a few years, just as great as the probability of a remission. The tendency towards a decreasing glucose tolerance or the manifestation of diabetes was furthered by initial existence or development of a higher overweight (more than 30%).