Predictors of 10-year outcome of first-episode psychosis

Remission and recovery during the first outpatient year of the early course of schizophrenia

BACKGROUND

Although in the early course of schizophrenia relapse prevention is of paramount importance, there is an increasing emphasis on establishing and maintaining sustained periods of symptom remission. Recovery in the early course of illness is also possible, although the rates of recovery are lower than for symptom remission. Symptom remission and recovery rates vary considerably across recent-onset schizophrenia studies because of a lack of consistency in treatment interventions and in applying operational outcome criteria.

METHOD

Patients who were within two years of their first psychotic episode (N=77) that were treated with continuous antipsychotic medication in conjunction with psychosocial interventions (without targeted work rehabilitation) were assessed during the first outpatient year after hospital discharge. Published operational criteria were used to classify symptom remission and recovery.

RESULTS

The rate of full symptom remission maintained for 6 months was 36%, while the rate of recovery for 6 months was 10%. When the same criteria were applied for a continuous period of one year, 22% of patients were found to achieve symptom remission but only 1% of patients met recovery criteria. Using multivariate prediction, the WAIS Comprehension score was a significant predictor of 6 months of good functional outcome.

CONCLUSIONS

Although some schizophrenia patients can achieve both symptom remission and recovery in the early course of illness, the overall rate of symptom remission during the first post-hospitalization year is much higher than the rate of recovery. This suggests that interventions targeting work and social functioning are likely necessary to raise the chances of recovery. Cognitive factors can be predictive of good functional outcome even in the early course of schizophrenia.

Remission after first-episode schizophrenia: results of a long-term follow-up

The aim of this study was to identify the rate and predictors of remission after first episode of schizophrenia (FES). Ninety-three FES patients were followed for at least 12 months and up to 12 years (mean=58.4 months) including monthly assessments with the Brief Psychiatric Rating Scale-Expanded (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS), and Scale for the Assessment of Negative Symptoms (SANS). We also administered the Premorbid Adjustment Scale (PAS). We used the remission criteria recently defined by Andreasen et al. (2005). Fifty-six (59.5%) patients met the remission criteria in the first 24 months of the follow-up period, but 40 (71.5%) of these patients could not maintain their status. However, 23 (57%) of these patients later met the remission criteria again. The remission group patients achieved a higher rate of employment both in the first year and overall. In the logistic regression analysis, lower negative and higher positive symptoms at admission, lower positive symptoms at month 3 of the follow-up, medication compliance in the first 6 months, and occupational status during the last month before admission were found related to remission status. Our findings suggest that the remission group has advantages in terms of occupational status and symptom severity compared with their counterparts who did not achieve or maintain a state of remission.

Social disability at admission for a first psychosis does not predict clinical outcome at 5-year follow-up

Although it has often been reported that premorbid social deficits are associated with clinical outcome in schizophrenia, the association between clinical outcome and social disabilities during admission for a first psychosis is still unclear. We examined whether a detailed assessment of social disability (assessed using the Groninger Social Disabilities Schedule-II) in the month before admission for a first psychotic episode contributed to the prediction of disease outcome in terms of psychopathology in 82 patients with schizophrenia. After controlling for the Positive and Negative Syndrome Scale sum score at baseline, none of the social disability domains significantly predicted the number of relapses or the severity of clinical symptoms at a 5-year follow-up. Our results suggest that poor social functioning at admission does not necessarily predict poor disease outcome. Following Di Michele and Bolino (Psychopathology 37:98-104, 2004), we hypothesize that, to reliably predict the course of schizophrenia, it may be necessary to assess social functioning during clinical stabilization.

Exposure to trauma and the clinical presentation of first-episode psychosis in South Africa

OBJECTIVE

To evaluate the relationship between a history of traumatic experiences and the clinical features of first-episode psychosis (FEP).

METHOD

We tested associations between trauma variables and duration of untreated psychosis (DUP), age of onset (AO), PANSS-rated positive and negative symptoms and depressive symptoms (Calgary Depression Scale) in a sample of 54 FEP patients.

RESULTS

Mean DUP was 34.4 weeks, while mean AO was 24.7 years. Witnessing a seriously violent assault (49%) was associated with high positive symptoms (p = 0.002), while a significant personal experience of racism and discrimination (39%) was associated with high depressive (p = 0.042) symptoms. Previous sexual assault (44% of females) was associated with high positive (p = 0.028) and negative (p = 0.035) symptoms with a trend association with depressive symptoms (p = 0.092).

CONCLUSION

Our findings suggest that previous traumatic experience is associated with positive and affective symptoms in FEP.

Remission in schizophrenia: validity, frequency, predictors, and patients' perspective 5 years later

In March 2005, the Remission in Schizophrenia Working Group (RSWG) proposed a consensus definition of symptomatic remission in schizophrenia and developed specific operational criteria for its assessment. They pointed out, however, that the validity and the relationship to other outcome dimensions required further examination. This article reviews studies on the validity, frequency, and predictors of symptomatic remission in schizophrenia and studies on patients' perspectives. These studies have demonstrated that the RSWG remission criteria appear achievable and sustainable for a significant proportion of patients, and are related to a better overall symptomatic status and functional outcome and, to a less clear extent, to a better quality of life and cognitive performance. However, achieving symptomatic remission is not automatically concurrent with an adequate status in other outcome dimensions. The results of the present review suggest that the RSWG remission criteria are valid and useful. As such, they should be consistently applied in clinical trials. However, the lack of consensus definitions of functional remission and adequate quality of life hampers research on their predictive validity on these outcome dimensions. Future research should therefore search for criteria of these dimensions and test whether the RSWG remission criteria consistently predict a “good” outcome with respect to functioning and quality of life.

Early identification of non-remission in first-episode psychosis in a two-year outcome study

OBJECTIVE

To identify predictors of non-remission in first-episode, non-affective psychosis.

METHOD

During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years.

RESULTS

One hundred and twenty-nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non-remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non-remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two-year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non-remission at 3 months, but only DUP predicted at 2 years.

CONCLUSION

Long DUP predicted both 3 month and 2-year non-remission rates in first-episode psychosis.

Beyond the first episode: candidate factors for a risk prediction model of schizophrenia

Many early psychosis services are financially compromised and cannot offer a full tenure of care to all patients. To maintain viability of services it is important that those with schizophrenia are identified early to maximize long-term outcomes, as are those with better prognoses who can be discharged early. The duration of untreated psychosis remains the mainstay in determining those who will benefit from extended care, yet its ability to inform on prognosis is modest in both the short and medium term. There are a number of known or putative genetic and environmental risk factors that have the potential to improve prognostication, though a multivariate risk prediction model combining them with clinical characteristics has yet to be developed. Candidate risk factors for such a model are presented, with an emphasis on environmental risk factors. More work is needed to corroborate many putative factors and to determine which of the established factors are salient and which are merely proxy measures. Future research should help clarify how gene-environment and environment-environment interactions occur and whether risk factors are dose-dependent, or if they act additively or synergistically, or are redundant in the presence (or absence) of other factors.

Redefining outcome measures in schizophrenia: integrating social and clinical parameters

PURPOSE OF REVIEW

Schizophrenia is a complex neurobehavioral disorder for which there are many promising new treatments. There is, however, a discrepancy in outcome measure reports when they are obtained from patients, relatives, caregivers, or professionals, making it difficult to determine the level of recovery. This lack of agreement may result from limitations of the measurement tools themselves, which are not comprehensive and may be measuring different aspects of outcome. Alternatively, it could be that the conceptual understanding of outcome and recovery require development.

RECENT FINDINGS

For various reasons, patients assessed as 'recovered' remain excluded from mainstream society. We are of the opinion that present outcome measures do not capture real-life situations. We propose that the concept of recovery be carefully defined and the gold standard of outcome should incorporate social and clinical parameters. We attempt to redefine recovery. Patients who have shown clinical improvement do not necessarily do well in everyday situations even though there is obvious clinical improvement. Therefore, it has been repeatedly argued that a consensus of recovery should be determined and that routine clinical practice should then adapt to the agreed criteria.

SUMMARY

We argue that the outcome measures should be multidimensional and consist of at least two parameters: clinical remission and social outcome.