Long-term prognosis and followup in schizophrenia

Short-term functional outcome in psychotic patients: results of the Turku early psychosis study (TEPS)

BACKGROUND

Functional recovery of patients with clinical and subclinical psychosis is associated with clinical, neuropsychological and developmental factors. Less is known about how these factors predict functional outcomes in the same models. We investigated functional outcomes and their predictors in patients with first-episode psychosis (FEP) or a confirmed or nonconfirmed clinical high risk of psychosis (CHR-P vs. CHR-N).

METHODS

Altogether, 130 patients with FEP, 60 patients with CHR-P and 47 patients with CHR-N were recruited and extensively examined at baseline (T0) and 9 (T1) and 18 (T2) months later. Global Assessment of Functioning (GAF) at T0, T1 and T2 and psychotic, depression, and anxiety symptoms at T1 and T2 were assessed. Functional outcomes were predicted using multivariate repeated ANOVA.

RESULTS

During follow-up, the GAF score improved significantly in patients with FEP and CHR-P but not in patients with CHR-N. A single marital status, low basic education level, poor work situation, disorganization symptoms, perceptual deficits, and poor premorbid adjustment in patients with FEP, disorganization symptoms and poor premorbid adjustment in patients with CHR-P, and a low basic education level, poor work situation and general symptoms in patients with CHR-N predicted poor functional outcomes. Psychotic symptoms at T1 in patients with FEP and psychotic and depression symptoms at T1 and anxiety symptoms at T2 in patients with CHR-P were associated with poor functioning.

CONCLUSIONS

In patients with FEP and CHR-P, poor premorbid adjustment and disorganization symptomatology are common predictors of the functional outcome, while a low education level and poor work situation predict worse functional outcomes in patients with FEP and CHR-N. Interventions aimed at improving the ability to work and study are most important in improving the functioning of patients with clinical or subclinical psychosis.

Fully recovered schizophrenics compared to chronic patients on premorbid and treatment characteristics

Ten fully recovered schizophrenics (Group A) were compared to 10 chronic schizophrenic patients (Group B) on several variables concerning premorbid adjustment, family interaction, hospitalization, and treatment. Patients in Group A were clearly, but not statistically significantly better than patients in Group B on premorbid adjustment. Likewise, a clear tendency toward an earlier onset of the illness in Group B patients was found. There were also differences between the 2 groups on some family interaction variables, firstly with regard to leadership in the farnily and parent capability for empathy and ability to give love and care. The most important differences were found, however, with respect to treatment. Almost all patients in Group A had been in psychotherapy, while this was only the case for 2 patients in Group B. Patients in Group A attached great importance to the psychotherapeutic treatment, and some also to their religious belief and/or the psychological support from their spouse, in explaining why they had been cured from the illness.

The development of Kraepelin's mature diagnostic concept of hebephrenia: a close reading of relevant texts of Hecker, Daraszkiewicz, and Kraepelin

In developing his mature concept of hebephrenic dementia praecox (DP) in his 4th (1893) through 6th textbook editions (1899), Kraepelin worked from the hebephrenic syndrome first described by Hecker (1871) and then carefully studied by his student Daraszkiewicz (1892). Working under Kraepelin's supervision, Daraszkiewicz followed Hecker in emphasizing several key features of hebephrenia (distinctive deteriorative course, importance of silliness and minimal positive psychotic symptoms) but expanded the syndrome to include cases developing severe dementia, rejected the link to prodromal depressive and manic phases, and reduced the emphasis on thought disorder. Daraszkiewicz proposed a soft subtyping of hebephrenia based on level of deterioration, which Kraepelin adopted in his 4th edition with an additional emphasis on severe positive psychotic symptoms. In his 5th edition, Kraepelin created a third subform with even more pronounced and bizarre delusions and hallucinations. In his 6th edition, which contained his first articulation of DP, Kraepelin eliminated his hebephrenia subforms presenting a single syndrome, which, compared to Hecker, included more emphasis on positive psychotic and catatonic symptoms and severe dementia. Kraepelin's paths to hebephrenic and paranoid DP differed in important ways. Paranoid DP was a de novo syndrome created by differentiation from paranoia. Hebephrenia, by contrast, evolved from a disorder created in the Kahlbaum/Hecker paradigm of the iterative study of clinical features, course and outcome. Kraepelin further implemented this approach in substantially reworking, over several drafts, the hebephrenic syndrome to fit into his emerging construct of dementia praecox.

Might Hallucinations Have Social Utility?: A Proposal for Scientific Study

There are many historical examples of people who heard voices or saw visions but were not classified as having a mental illness and who were supported by a religious community. The article offers a perspective for effective psychosocial supports for schizophrenia. The author analyzes data on 95 people who experienced verifiable persistent non-drug-assisted hallucinations in Europe, North America, and Australasia and discusses the life outcomes of 39 subjects. They include founders of religions, dysfunctional monarchs, persons with cosmological beliefs, and mental health workers. Their psychoses were intrinsic to their personalities and contributions. Hallucinations generated by psychosis were useful for cultural innovation, particularly in religion as many hallucinators were integrated into church history. Community, work, friendship, and supportive practices are discussed. A scientific study of effective psychosocial support to supplement medication for schizophrenia is outlined.

Assessment of DNA damage and repair efficiency in drug naïve schizophrenia using comet assay

The etiology of schizophrenia continues to be confounding and elusive. Some knowledge gaps exist in the neurodegenerative theory of schizophrenia. Oxidative DNA damage and repair deficits are relevant to the mechanisms of neurodegeneration but have not been studied in drug naïve schizophrenia. The present study used the comet assay technique to study the extent of DNA damage in circulating peripheral lymphocytes of patients with drug naïve schizophrenia (n = 40) along with an age and gender matched control group (n = 40). We also assessed the DNA repair efficiency in cases following incubation in a nutrient medium. All the assayed comet parameters demonstrated significantly greater baseline DNA damage in cases in comparison to the controls except for head diameter (p < 0.001 for all significant results, p = 0.32 for head diameter). Gender, age and duration of illness (p = 0.21, 0.69 and 0.12 respectively for tail length) did not influence any of the parameters significantly. Significant decrease was noted in the comet tail length and percentage of DNA in comet tail (p < 0.001 for both) in cases following incubation suggesting that the DNA repair machinery was preserved. No difference in DNA repair efficiency was noted between the genders (p = 0.23 for tail length). Our findings confirm the presence of significant baseline DNA damage in schizophrenia even prior to the initiation of anti-psychotic treatment. Additionally, intact genomic repair efficiency was noted in this group as a whole. These results provide some evidence for oxidative DNA damage as molecular link underpinning neurodegeneration in drug naïve schizophrenia.

Course and outcome of schizophrenia in asian countries: review of research in the past three decades

Considerable variation has been observed in the course and outcome of schizophrenia. With regard to epidemiology of schizophrenia, papers from different Asian countries have reported findings which are in contrast with literature from the western countries. In this background we undertook a narrative review of literature regarding course and outcome of schizophrenia in Asian countries. We conducted Medline search for English-language papers on long-term course and outcome of schizophrenia conducted in Asia in the past 3 decades. We also reviewed data pertaining to Asian countries from the World Health Organization's International Study of Schizophrenia (ISoS). In addition to ISoS, we retrieved 14 reports from 9 Asian countries. While ISoS used comparable methodology across the countries, non-ISoS studies differed substantially in their aims, sampling, follow-up rates and assessment tools used for studying the course and outcome. Overall, the percentage of patients who experienced clinical and functional outcome in the Asian countries were largely comparable to those in the western studies. We observed significant variations in the long-term outcome and mortality in schizophrenia even among the Asian countries. In conclusion, there is substantial variation in the long-term course and outcome and mortality across different Asian countries. The reason for this remains unexplored. Cross-national studies exploring biological and cultural explanations for this variation may provide clues, which may have heuristic, translational and public-health significance.

A review on schizophrenia and relapse--a quest for user-friendly psychopharmacotherapy

OBJECTIVE

Schizophrenia in general is notoriously associated with relapses rendering the illness progressive to worse outcomes, a concept of which is compatible with neurotoxicity. Therefore, relapse prevention is of utmost clinical relevance.

METHODS

In this review, we aim to put relapse into clinical context in the realm of natural history of, or heterogeneity in, schizophrenia and summarize risk factors of relapse. We discuss how to effectively 'define' relapse in schizophrenia and recent meta-analytic studies on this topic to highlight the importance of continuous antipsychotic treatment.

RESULTS

The following issues emerged: 'How low maintenance antipsychotic dosage could be?’, 'How extended dosing could be?’, 'Who could be successfully withdrawn from antipsychotics?’ and 'How relapse could be defined in the first place?’ The question in particular is how better to deliver antipsychotics at the lowest possible, whereby dose and dosing interval are relevant. While ongoing antipsychotic treatment is the rule, recent works are pointing to a possibility of lower dosage in the maintenance phase of the illness.

CONCLUSIONS

Bearing in mind that suboptimal adherence and withdrawal from antipsychotics are an established and unequivocal risk factor for relapse, further investigations are certainly needed to explore user-friendly manner of psychopharmacotherapy to prevent relapse in schizophrenia.

Outcome studies in schizophrenia

Objectives:To outline the limitations of traditional studies of outcome in schizophrenia and to review the findings arising from ‘first episode’ psychosis studies.

Method:An extensive literature search was performed and relevant papers were examined and analysed.

Results:Current knowledge regarding outcome predictors in schizophrenia has primarily been derived from a series of ‘consecutive admission’ and ‘long-term follow-back’ studies. However, methodological considerations may limit the generalisability of these studies' findings. The prospective evaluation of first episode cohorts has advanced our knowledge regarding the relative importance of premorbid and intercurrent factors in determining outcome in schizophrenia.

Conclusions:To date, the ‘first episode’ strategy has highlighted some potentially clinically modifiable outcome predictors. These findings may open the way for targeted introduction of measures aimed at preventing poor outcomes in schizophrenia.

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

[Quality of life in patients with schizophrenia: a study of 100 cases]

OBJECTIVE

The aim of the present study was to evaluate the quality of life (QOL) in outpatients with schizophrenia, and to identify factors correlated to an impaired QOL among them.

SUBJECTS AND METHODS

A transversal study, in the form of an inquiry, was conducted in 100 outpatients, during seven months, in the psychiatric department of the Hedi Chaker teaching hospital in Sfax - Tunisia. We used the "36 item Short-Form Health Survey" (SF-36) to assess the QOL; this has been considered as impaired when the global medium score was inferior to 66.7. For the global assessment of functioning and the global assessment of the interference by existing side effects with the patient's daily performance, we have used respectively the Global Assessment of Functioning scale (GAF) and the Udvalg of Kliniske Undersogelser (UKU) side effect rating scale. The positive and negative symptoms added to the general psychopathology were assessed using the Positive and Negative syndrome scale (PANSS).

RESULTS

The QOL was impaired in 34% of the cases. The analysis of the scores of the eight dimensions by the scale SF-36 has shown that the most affected dimensions were, in decreasing order: mental health (MH), general health perceptions (GH), vitality (VT), role limitations due to physical health problems (RP) and role limitations due to emotional problems (RE). The standardization revealed that six dimensions were impaired; these were, in decreasing order: mental health (MH), social functioning (SF), role limitations due to emotional problems (RE), role limitations due to physical health problems (RP), general health perceptions (GH) and physical functioning (PF). The standardization has also revealed an impairment of the psychological component, while the physical component has been conserved. After analysis by multiple linear regression, four factors appeared strongly correlated with the impaired QOL: the professional inactivity, the episodic course with interepisode residual symptoms, the presence of side effects moderately influencing the daily performance, and a general psychopathology score for 26 at least. These four factors affected, in decreasing order of importance, social functioning (SF) (related to two factors), general health perceptions (GH) and role limitations due to emotional problems (RE) (each related to one factor). None of the factors appeared to affect the other dimensions: physical functioning (PF), role limitations due to the physical health problems (RP), bodily pain (BP), mental health (MH) and vitality (VT). The bivariate analysis revealed three other factors correlated, to a lesser degree, to the impairment of the QOL: the disorganized sub-type, a score of (GAF) inferior or equal to 30 and the negative type of schizophrenia.

CONCLUSION

Management of schizophrenic patients should go beyond the remission of the symptoms; it has also to target the improvement in QOL. This needs an action over the factors that affect the QOL, among which residual symptoms and side effects. The atypical antipsychotics would contribute preciously in this way, due to their efficacy on negative symptoms and their better tolerance than the conventional ones.

Patterns of clinical course in persons with mental disorders: which impact on social disability and quality of life? A longitudinal study

Summary

Aims — To investigate in persons with mental disorders 1) the patterns of clinical course and their frequencies, 2) the impact of clinical course on two social dimensions of outcome, such as disability and quality of life. Methods — Study conducted with a longitudinal design in the “real world” of community mental health services. Clinical course was retrospectively assessed by using an instrument developed by our group, taking into account previous literature in this area; disability and quality of life were measured, respectively, with the WHO—Disability Assessment Schedule and the Lancashire Quality of Life Profile. Results — In patients with non affective psychosis, continuous and episodic course showed the same tendency to occur, whereas in subjects with affective disorders (either psychotic or neurotic) episodic course was more frequent. Continuous course was associated with higher levels of disability and lower quality of life in psychotic patients, while a poorer quality of life in some areas was associated with episodic course in patients with non psychotic disorders. Conclusions — The impact of clinical course on social disability and quality of life is different depending upon the specific diagnostic category. This suggests that specific and individualised interventions should be provided in order to prevent the negative impact of clinical course on life conditions of persons with mental disorders.

Declaration of Interest

the study has been supported by a Grant from MURST 60% to Prof. Mirella Ruggeri and Fondi 1% per la Ricerca Sanitaria Finalizzata 2001 Ministry of Health, to Professor M. Tansella.

Naming psychosis: the Hong Kong experience

AIM

Schizophrenia translates in Chinese as 'Mind Split Disease' which is heavily stigmatizing. The narrow conceptualization for schizophrenia alone was insufficient, in the context of early detection and intervention for psychosis. The need for an effective Chinese translation for psychotic disorders was imminent upon the launch of the Early Assessment Service for Young People with Psychosis in Hong Kong, where public awareness strategies had to be built upon effective communication of the disorder.

METHODS

'Si Jue Shi Tiao', the new term for psychosis, described 'thought and perceptual dysregulation'. This new terminology and concept was strategically introduced to the local community.

RESULTS

The term 'Si Jue Shi Tiao' was taken up well locally and had demonstrated interactions within the Chinese and East Asian communities. The public has taken in the broader concept of psychosis, in contrary to the previous concept of schizophrenia per se.

CONCLUSIONS

In Hong Kong, the restrictive view of perceiving psychotic disorders as schizophrenia was broadened upon the introduction of a more embracing, less stigmatizing term 'Si Jue Shi Tiao'. Effective establishment of this term to the local vocabulary allowed a basis for communication as well as public education work. Further evaluation is necessary to determine the effectiveness of the naming and to guide further public awareness strategies.

How frequent is chronic multiyear delusional activity and recovery in schizophrenia: a 20-year multi-follow-up

To determine how frequent chronic multiyear delusional activity is in modern-day schizophrenia, we studied 200 patients over a 20-year period. We also studied the relation of delusions to hallucinations and thought disorder-disorganization, to work disability, and to later periods of global recovery and assessed several protective factors against delusional activity. The sample was assessed 6 times over 20 years and includes 43 patients with schizophrenia. Participants were evaluated at each follow-up for delusions, hallucinations, thought disorder-disorganization, work disability, and global recovery. Possible protective factors were assessed prospectively at index hospitalization. Twenty-six percent of the patients with schizophrenia were delusional at all follow-ups over the 20 years. Overall, 57% had frequently recurring or persistent delusions. A subgroup of over 25% of the schizophrenia patients had no delusional activity at any of the 6 follow-ups over 20 years. Schizophrenia patients with posthospital delusional activity had increased work disability (P < .05). Delusions that persisted after the acute phase in schizophrenia patients predicted a lower likelihood of future global recovery (P < .01). In conclusion, slightly over half of modern-day schizophrenia patients are vulnerable to frequent or "chronic" delusional activity after the acute phase. Schizophreniform patients and other types of psychotic disorders are vulnerable to posthospital delusional activity, but less frequently, less severely, and more episodically. Delusional activity is associated with work disability. Internal factors such as good premorbid developmental achievements and favorable prognostic factors are protective factors that reduce the probability of chronic multiyear, delusional activity in schizophrenia (P < .01).

Schizophrenia

Schizophrenia is still one of the most mysterious and costliest mental disorders in terms of human suffering and societal expenditure. Here, we focus on the key developments in biology, epidemiology, and pharmacology of schizophrenia and provide a syndromal framework in which these aspects can be understood together. Symptoms typically emerge in adolescence and early adulthood. The incidence of the disorder varies greatly across places and migrant groups, as do symptoms, course, and treatment response across individuals. Genetic vulnerability is shared in part with bipolar disorder and recent molecular genetic findings also indicate an overlap with developmental disorders such as autism. The diagnosis of schizophrenia is associated with demonstrable alterations in brain structure and changes in dopamine neurotransmission, the latter being directly related to hallucinations and delusions. Pharmacological treatments, which block the dopamine system, are effective for delusions and hallucinations but less so for disabling cognitive and motivational impairments. Specific vocational and psychological interventions, in combination with antipsychotic medication in a context of community-case management, can improve functional outcome but are not widely available. 100 years after being so named, research is beginning to understand the biological mechanisms underlying the symptoms of schizophrenia and the psychosocial factors that moderate their expression. Although current treatments provide control rather than cure, long-term hospitalisation is not required and prognosis is better than traditionally assumed.

Definitions of the term 'recovered' in schizophrenia and other disorders

BACKGROUND

The use of the term 'recovered' in outcome studies of schizophrenia has for a long time been problematic because of the many different definitions in use. In the present study different definitions of recovered in schizophrenia are reviewed and compared with similar definitions in other fields of medicine.

SAMPLING AND METHODS

A literature search was done for criteria-based definitions of recovered as used in follow-up studies of patients with schizophrenia during the last 50 years and the current use of the term in other fields of medicine.

RESULTS

In medicine, only the field of psychiatry defines the term recovered to be synonymous with no or minimal signs of illness. Other fields only apply the term when studying the outcome of a specific function. In psychiatry, only the field of schizophrenia includes both symptoms and functioning in the definition. All but 1 of the 18 definitions found in use in the field of schizophrenia required minimal or no symptoms, while all differed in defining functional recovery. Recovered was seldom defined as following from a state of remission, and studies varied in requiring a stable phase.

CONCLUSION

When using the term in the field of schizophrenia, a distinction should be made between symptomatic and functional recovery in order to place it in line with other fields of medicine. To avoid confusing the process of recovery from the state of being recovered, the term recovered should be reserved for use in outcome studies, following from a time in remission. We suggest 2 years.

Predicting clinical and social outcome of patients attending 'real world' mental health services: a 6-year multi-wave follow-up study

OBJECTIVE

The aims of this study were: i) to determine changes in symptoms and social disability, and ii) to explore predictors of clinical and social outcome in patients receiving community-based mental health care.

METHOD

A total of 354 patients treated in the South-Verona Community Mental Health Service were followed up over 6 years (with assessments made at baseline, 2 and 6 years) by using a set of standardized measures exploring psychopathology (Brief Psychiatric Rating Scale) and social disability (Disability Assessment Schedule). Generalized linear latent and mixed models were used to explore longitudinal predictors of clinical and social outcome.

RESULTS

Psychotic patients displayed clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however, a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are fatally prone to a destiny of chronicity. Non-psychotics reported a significant reduction in the core symptom of depression and in the observable physical and motor manifestations of tension and agitation, and a parallel increase in complaints about their physical health. Clinical and social dimensions of outcome are influenced by specific and different set of predictors.

CONCLUSION

The results of this study confirm the need to implement naturalistic outcome studies conducted in the 'real world' services to inform decisions and strategies to be adopted in routine clinical practice.

Very poor outcome schizophrenia: clinical and neuroimaging aspects

In spite of significant advances in treatment of patients with schizophrenia and continued efforts towards their deinstitutionalization, a considerable group of patients remain chronically hospitalized or otherwise dependent on others for basic necessities of life. It has been proposed that these patients belong to a distinct etiopathological subgroup, termed Kraepelinian, whose course of illness may be progressive and resistant to treatment. Indeed, longitudinal studies appear to show that elderly Kraepelinian patients follow a course of rapid cognitive and functional deterioration, commensurate with a dementing process, and that their poor functional status is closely correlated with the cognitive deterioration. Recent neuroimaging studies described a pattern of posteriorization of grey and white matter deficits with poor outcome in schizophrenia, and produced a constellation of findings implicating primary processing of visual and auditory information as central to the impaired functional status in this patient group. These studies are summarized in detail in this review and future directions for neuroimaging assessment of very poor outcome patients with schizophrenia are suggested.

A comprehensive assessment of gray and white matter volumes and their relationship to outcome and severity in schizophrenia

Preliminary data suggest an association of posterior cortical gray matter reduction with poor outcome in schizophrenia. We made a systematic MRI assessment of regional gray and white matter volumes, parcellated into 40 Brodmann's areas, in 104 patients with schizophrenia (51 with good outcomes, 53 with poor outcomes) and 41 normal comparison subjects, and investigated correlations of regional morphometry with outcome and severity of the illness. Schizophrenia patients displayed differential reductions in frontal and to a lesser degree temporal gray matter volumes in both hemispheres, most pronounced in the frontal pole and lateral temporal cortex. White matter volumes in schizophrenia patients were bilaterally increased, primarily in the frontal, parietal, and isolated temporal regions, with volume reductions confined to anterior cingulate gyrus. In patients with schizophrenia as a group, higher illness severity was associated with reduced temporal gray matter volumes and expanded frontal white matter volumes in both hemispheres. In comparison to good-outcome group, patients with poor outcomes had lower temporal, occipital, and to a lesser degree parietal gray matter volumes in both hemispheres and temporal, parietal, occipital, and posterior cingulate white matter volumes in the right hemisphere. While gray matter deficits in the granular cortex were observed in all schizophrenia patients, agranular cortical deficits in the left hemisphere were peculiar to patients with poor outcomes. These results provide support for frontotemporal gray matter reduction and frontoparietal white matter expansion in schizophrenia. Poor outcome is associated with more posterior distribution (posteriorization) of both gray and white matter changes, and with preferential impairment in the unimodal visual and paralimbic cortical regions.

Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study

This prospective longitudinal 15-year multifollow-up research studied whether unmedicated patients with schizophrenia can function as well as schizophrenia patients on antipsychotic medications. If so, can differences in premorbid characteristics and personality factors account for this? One hundred and forty-five patients, including 64 with schizophrenia, were evaluated on premorbid variables, assessed prospectively at index hospitalization, and then followed up 5 times over 15 years. At each follow-up, patients were compared on symptoms and global outcome. A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001). The longitudinal data identify a subgroup of schizophrenia patients who do not immediately relapse while off antipsychotics and experience intervals of recovery. Their more favorable outcome is associated with internal characteristics of the patients, including better premorbid developmental achievements, favorable personality and attitudinal approaches, less vulnerability, greater resilience, and favorable prognostic factors. The current longitudinal data suggest not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives.

Long-term follow-up of patients with a diagnosis of paranoid state and hospitalized, 1913 to 1940

From a sample of 239 patients diagnosed paranoid state and hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied a group of 60 patients without previous hospitalizations, consisting of 57 patients with follow-ups of 5 or more years, and 3 patients who killed themselves (the ultimate follow-up) less than 1 year after discharge. These 60 patients had been retrospectively diagnosed with delusional disorders by DSM-IV criteria. On follow-up, 27% were rated recovered, whereas 52% were rated unimproved. Long-term follow-up was correlated with discharge status. Poor follow-up was significantly correlated with seclusive personality, poor premorbid history, onset 6 months or more before admission, gradual onset, lack of insight, single marital status, and lack of precipitating events. A prognostic scale constructed from the first four of these variables was predictive of long-term outcome. More recent, better treatment results have been contrasted with these findings from an earlier non-drug-treatment era.

From first episode to long-term care: The need for sustained clinical commitment

There is considerable evidence to suggest that many patients experience difficulties in gaining access to treatment after the onset of significant symptoms and social disability. Delay in obtaining appropriate support and treatment can have profound effects on both the patient and their family and may also be associated with a poorer long-term outcome. As stated in the Principles of Practice, prompt and comprehensive clinical assessment, by a clinician experienced in the recognition and treatment of severe mental illness, is therefore important for achieving the best possible outcome for the patient. The primary objectives of early-stage treatment for schizophrenia are to achieve a full improvement in psychopathological symptoms and a recovery of premorbid levels of function. However, even with optimal treatment, the reality for many patients is that their symptoms and impairment continue. Many patients can therefore be regarded as only partially responsive, or even resistant, to treatment. When assessing the utility of an antipsychotic treatment regimen for such patients, clinicians should not just consider the objective manifestations of the disorder but also the subjective experience of the patient. Relapse of illness is also a common and serious problem for many patients with schizophrenia, despite continual treatment. Prevention and management of relapse are two of the main challenges in the effective treatment of schizophrenia. The optimal use of antipsychotic treatment and the adherence by patients to that treatment offer valuable protection against relapse. Symptoms of depression or low mood affect a high proportion of patients with schizophrenia at some point in their illness and are also associated with an increased risk of relapse. Treatment objectives in the early stages may need to be modified if a pattern of partial response or resistance to treatment, a cycle of relapse of the illness or the presence of depressive symptoms, develops. Clinicians should continue to offer a sustained and positive clinical commitment to all.

Full recovery from schizophrenia: the prognostic role of premorbid adjustment, symptoms at first admission, precipitating events and gender

A number of long-term studies of course and outcome in schizophrenia report that about a fourth of the cases show good clinical and social recovery. However, very few studies have been carried out examining the main characteristics of schizophrenia patients who have fully recovered according to a strict definition of 'full recovery'. The purpose of the present study was, therefore, to compare a group of 17 fully recovered schizophrenia patients (Group A) with a group of 33 patients (Group B) with current symptoms of schizophrenia on several prognostic factors that have been associated with a good outcome. These clinical groups were matched groupwise with a similar mean on two variables: age range at onset of illness and age at time of interview. Duration of illness (length of time from age of onset of illness to time of assessment) was 22.4 years in group A and 21 years in group B. Mean GAS scores were 72.2 and 46.5, respectively. Positive symptoms (delusions and disorganized behavior) at admission predicted an unfavorable outcome. The results confirmed the prognostic significance of several clinical and demographic factors. However, a good premorbid adjustment did not show significant predictive power, but showed substantial association in the predicted direction. In addition, a clear sex difference was found: women report a significantly better premorbid functioning and demonstrate a more favorable psychosocial functioning than men.

Suicide in patients hospitalized for schizophrenia: 1913-1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Age and mental health services

This paper examines how age is related to the use of formal and informal mental health services, adjustment to current life conditions, and expectations for improvement in future life conditions among a group of persons with serious mental illnesses. Interviews with 301 clients of 3 clinics at a public psychiatric facility serving West Brooklyn and Staten Island provide the data from the study. Outcome measures include nine sorts of help received from informal members of the social network and from mental health professionals; desires to improve current life conditions; and expectations for future improvements in life conditions. Through hierarchical regression procedures we examine the impact of age on these outcomes, with controls for self-reported symptoms and functioning, sex, and the presence of social network members. The results indicate that younger people receive more help from both informal social networks and from mental health professionals. In addition, younger people are more likely to want improvements in their current life conditions and to be optimistic about what the future holds for them. The decline in informal and formal support, optimism, and desire to improve their current life situations among older clients may be cause for concern among mental health professionals. Mental health service providers should give greater recognition to the impact of age on mental health service needs among persons with serious mental illnesses.

"Full recovery" from schizophrenia in the long term: a ten-year follow-up of eight former schizophrenic patients

The present study reports longitudinal data on individuals who ten years ago were fully recovered from a previously diagnosed schizophrenia. Seven out of ten subjects consented and were reexamined at the present follow-up, and data on an eighth subject was secured elsewhere. A semistructured interview was used to examine psychosocial functioning of the subjects in the follow-up period. Out of the six subjects with a confirmed diagnosis of schizophrenia, only three subjects were still fully recovered; one had a deteriorating course and two had a fluctuating course of illness. The results from the study indicate that recovery from schizophrenia may take the form of time-limited remissions for half of the reexamined subjects when strict criteria for full recovery are used. Protective factors such as willpower, a (partly) intact capacity for object attachment, and a supportive family may be important prerequisites for recovery. Two different courses of schizophrenia are illustrated by cases.

Long-term follow-up of patients hospitalized for schizophrenia, 1913 to 1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied 484 patients with follow-ups of 5 or more years. Of the sample of 1357 patients, 28 (10%) committed suicide. None of the suicides were included in the sample of 484, which also eliminated all patients with any previous psychiatric admissions or episodes of mental illness, even without hospitalization. On follow-up, only 13% of the 484 were rated recovered, whereas 58% were rated unimproved. Long-term global follow-up was highly correlated with discharge status. Subgroups retrospectively diagnosed by DSM-IV criteria were significantly related to long-term follow-up in the sample of 484 patients, there being a continuum of poor outcome ranging from the diagnoses schizophrenia through schizophreniform to schizoaffective. Poor follow-up was significantly correlated with poor premorbid history, gradual onset, lack of depressive symptoms and heredity, seclusive personality, lack of precipitating events, lack of confusion, single status, onset before age 21, delusions of control, onset 6 months or more before admission, and emotional blunting. These variables were used to construct a validated prognostic scale. More recent treatment results have been contrasted with these findings from an earlier non-drug treatment era.

Outcome of schizophrenia: the Madras longitudinal study

OBJECTIVE

The aim of the study was to determine the clinical outcome in a group of first-episode schizophrenic patients on a 10-year follow-up. The social, demographic and clinical variables associated with poor outcome and gender differences in outcome were other issues addressed.

METHOD

Ninety patients fulfilling Feighner's and ICD-9 criteria for schizophrenia, at Madras, India, were included for a 10-year follow-up. The Present State Examination and the Psychiatric and Personal schedule were administered at intake and at the end of every year. Clinical outcome was considered as a combination of the pattern of course and the presence of positive symptoms during year 10.

RESULTS

After 10 years, 76 of the 90 patients included were followed up, giving a follow-up rate of 84%. The clinical outcome was good in nearly 75% of the patients with almost all symptoms showing a steep decline at the end of 10 years. Fifty-nine subjects were asymptomatic at the end of the follow-up period and 12 were ill during the entire 10th year. Sexual, religious and grandiose delusions and flat affect at inclusion predicted a poor clinical outcome. More males had a poor outcome and spent a longer time in a psychotic state.

CONCLUSIONS

There is evidence of a good outcome in the majority of first-episode schizophrenic patients after 10 years in keeping with other reports from developing countries. Certain variables at inclusion predicted a poor clinical outcome and males had a poorer outcome than females.

The nature of 'transient' and 'partial' psychoses: findings from the Northwick Park 'Functional' Psychosis Study

Three hundred and twenty-six consecutively admitted patients with definite or possible functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2.5 years. In 86 cases symptomatology had been inadequate for the patients to enter the functional psychosis study, and in 75 cases this was because the symptoms were partial or transient. These patients were compared at follow-up with those who fulfilled operational criteria for schizophrenic, affective or schizoaffective psychoses. Differences between the 'partial' cases and those fulfilling specific diagnostic criteria were few, but the transient cases fared significantly better. Although the transient illnesses were recurrent, at follow-up at 2.5 years they appeared to have a good outcome in terms of social variables and symptomatology.

A prospective 1-5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity, premorbid adjustment, duration of disease and education level at index admission and neuroleptic treatment

In a prospective outcome study, 120 DSM-III-R schizophrenic patients were followed for up to 5 years after index admission, when a comprehensive clinical and demographical examination was undertaken with the aim to find early prognostic factors for outcome. They were 86 males (72%) and 34 females (28%), and 66 (55%) were first-admitted and never before treated at index admission from a geographically defined area. Outcome was evaluated 1, 3 and 5 years after index admission by use of a Strauss-Carpenter outcome scale. At year five, 101 patients could be evaluated. Seven (7%) patients had committed suicide during the 5 years' follow-up period. 30% of the patients was considered to have a good, 14% a poor and 56% an intermediate outcome. It was found that 58% had not been in hospital during the last year, 27% were employed on the open market, 25% met friends regularly and 38% had no or only mild symptoms at the five years' follow-up evaluation. Females had a significantly better outcome than males. High education level and absence of premorbid deviant behaviour at index admission predicted a good outcome whereas problems in school (with friends and/or teachers) reported by relatives predicted poor outcome. No relationship was found between outcome and age at onset of the disorder and no gender difference in age at onset of the disorder. Patients with a family history of schizophrenia improved more between year one and five as compared with those without a family history, but heredity in itself was not an important factor for outcome. At 5 years after index admission, 40% of patients were on classical neuroleptics and 33% on clozapine whereas 19% were without medication. Of the total sample of 101 patients, 10% were drug-free and had a very good outcome at the 5 years' evaluation. The data indicate that there is a substantial subgroup of schizophrenic patients with a good prognosis and they can be characterized by female sex (even in a group without gender difference in age at onset), absence of premorbid deviant behaviour and a high education level at index admission.

Methodological aspects of onset assessment in schizophrenia

Psychiatric disorders in general and schizophrenia in particular often begin with a prodromal phase progressing into more specific syndromes long before the first treatment contact. More longitudinal studies on course and outcome of schizophrenia begin with first hospital admission not taking into account the preceding early course. The reason for this is the unsurmountable difficulties in observing and assessing real onsets with unspecific symptomatology directly and collecting a sufficient number of 'precontact' cases of rare diseases in the general population. There are in principle two practical ways of assessing time and type of onset and the early course of schizophrenia: the application of a screening procedure for establishing a prospective approach, e.g. the study of individuals at high risk for schizophrenia, and the retrospective assessment of the preceding course carried out at first treatment contact. Methodologically both strategies share the same problems, especially recall bias. In a comprehensive discussion of methodological issues ways are described to reduce and even control recall deficits by using appropriate techniques (standardised assessment with the IRAOS, the 'Interview for the Retrospective Assessment of the Onset of Schizophrenia'; time grids; interval assessment, comparison of independent sources of information etc.). A representative sample of 232 patients with a first episode of schizophrenia were selected from the 276 first admissions of the ABC schizophrenia study taken from a German population of 1.5 million. Results are represented for the crucial questions: when, how and with what symptoms does schizophrenia begin and how does the disorder develop up to the first admission? For example, the gender-specific mean age at different points in time during the development of the disease is presented, and the sequence and cumulation of symptoms in the early course examined. Additionally, the consecutive fulfillment of DSM-III criteria sets for schizophrenic and schizophreniform disorders are presented along with the frequency of different types of onset in schizophrenia.

Ten-year course of schizophrenia--the Madras longitudinal study

Ninety first-episode patients fulfilling ICD-9 criteria for schizophrenia were followed up prospectively for 10 years. Complete assessments were possible on 76. The pattern of illness was good in 67% of the cases, and the commonest patterns was one with recurrent episodes. Predictors of poor course and longer time spent in psychosis were identified. All positive and negative symptoms showed a steep decline at the end of 10 years. The results are discussed in the context of longitudinal research on the course of schizophrenia in developing countries.

Predictors of employment status of treated patients with DSM-III-R diagnosis. Can logistic regression model find a solution?

To investigate the predictors of employment status of patients with DSM-III-R diagnosis, 55 patients were selected by a simple random technique from the main psychiatric clinic in Al Ain, United Arab Emirates. Structured and formal assessments were carried out to extract the potential predictors of outcome of schizophrenia. Logistic regression model revealed that being married, absence of schizoid personality, free or with minimum symptoms of the illness, later age of onset, and higher educational attainment were the most significant predictors of employment outcome. The implications of the results of this study are discussed in the text.

Predictability of rehospitalization for schizophrenia

This analysis examines the predictability of the course of schizophrenia using long-term follow-up data on hospital episodes in a cohort of patients from a psychiatric case register in Denmark. We focus on whether clinical and sociodemographic data collected during the first episode are related to the number of hospitalizations during follow-up and the association of patients' course of hospitalizations with the risk of being rehospitalized. A Poisson regression model and a proportional hazards model were used to address these questions. Age of onset and time to the first rehospitalization were strong early predictors of chronicity of course, as measured by the number of psychiatric hospitalizations for each schizophrenic patient. The results also show that the risk of rehospitalization depends on the previous tenures in the community.

Social outcome in schizophrenia: a 13-year follow-up

The cohort consists of all psychiatric patients (n = 53) admitted for the first time in 1972 from a well-defined catchment area with a population of 582,000 inhabitants aged 15 years and over. Furthermore, they were all registered with the diagnosis schizophrenia in the nation-wide psychiatric register at least once during an observation period from the day of the first admission in 1972 until August 31, 1983. The entire cohort was followed up on average 13 years after their first admission. Poor employment outcome (79%), poor social contact outcome (55%), and poor overall social outcome (76%) characterized the living conditions of the 42 patients alive at follow-up. Good employment outcome was predicted by "born in rural area." Good social contact outcome was predicted by full remission at first discharge and poor outcome by male sex. Good overall social outcome was predicted by "born in rural area" and of marginal significance by high social status at first admission. A comparison of parents' highest social group and patients' social group at follow-up supports previous findings on social drift.

The Northwick Park 'Functional' Psychosis Study: diagnosis and outcome

Three hundred and twenty-six consecutively admitted patients with functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2.5 years. They were examined in social, clinical and psychological terms and the CATEGO programme and DSM-III criteria were applied to data concerning the index episode to derive diagnostic classifications. The deterioration in occupational functioning and the hospital careers of patients with diagnostic classifications of schizophrenia were worse than those in the other groups and positive and negative features were also more severe in patients with a classification of schizophrenia. By contrast, no differences in psychological test performance were found between the groups based upon diagnostic classification. Impaired psychological test performance was found and it was strongly related to concurrent mental state abnormalities, particularly negative symptoms. It is concluded that the diagnostic classifications used were of limited value in predicting outcome in functional psychosis.

Outcome in untreated schizophrenia: a search for symptoms and traits with prognostic meaning in patients admitted to a mental hospital in the preneuroleptic era

A cohort of schizophrenic patients consecutively admitted to a mental hospital for the first time in 1925 was investigated in search of symptoms and traits with prognostic meaning. Since Leonhard's diagnostic system was applied, cases with mixed symptoms and a favourable outcome were excluded as being neither schizophrenic nor manic-depressive. Owing to the admission policy then prevailing, cases with clinically less striking and socially less deleterious features were underrepresented. The sample (n = 70), so demarcated, was still considered fairly appropriate for the purpose of a differential study of outcome in nuclear schizophrenia with a life-long follow-up. The best outcome group consisted of 33% of the sample; 24% formed an intermediate group, and 43% profoundly deteriorated with continuous psychotic symptoms and a total loss of social function. Marriage before index admission was the only characteristic related to a favourable outcome. Nuclear schizophrenic symptoms, thought disturbance, blunted affect and all catatonic symptoms listed in DSM-III were related to an unfavourable outcome. When prognostic subgroups were compared pairwise, no favourable trait was detectable, and there were no decisive differences between the group with the best outcome and the intermediate group. When these 2 groups were compared with the group with worst outcome, however, significant differences arose with respect to unfavourable characteristics. Predictions using a discriminant analytic procedure yielded the same results. The hypothesis that affective and atypical signs would also have prognostic meaning in nuclear schizophrenia was disproved.

IRAOS: an instrument for the assessment of onset and early course of schizophrenia

Since Kraepelin's first description of dementia praecox in 1889 many data and theories have been published on the onset and course of schizophrenia. Until now studies on these topics had to rely on first admission data and on the subsequent course of the disease. However, first hospitalisation is preceded by a wide variety of patterns and duration of the early course. Items taken from the pre-admission phase of the disease are often incorrectly used as premorbid characteristics, understandably preceding the subsequent course and outcome of schizophrenia with high predictive power. In relation to our interest to study the beginning of schizophrenia, systematically, paying special attention to the age and gender distribution of true onset and the symptomatology and pattern of the early and later course, we developed an 'Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)'. It allows an objective, reliable, and valid assessment of the symptoms, psychological impairments, demographic and social characteristics as well as the referring points in time of the early course of psychosis. The instrument is administered as a semi-structured interview with both the patient and a key informant. The obtained information is extended by a systematic examination of the clinician's case notes. Some results derived from an ongoing study on age and gender differences in onset and patterns of early course are added to demonstrate the use of the instrument.

The International Pilot Study of Schizophrenia: five-year follow-up findings

A five-year follow-up of the patients initially included in the International Pilot Study of Schizophrenia was conducted in eight of the nine centres. Adequate information was obtained for 807 patients, representing 76% of the initial cohort. Clinical and social outcomes were significantly better for patients in Agra and Ibadan than for those in the centres in developed countries. In Cali, only social outcome was significantly better.

A 15-year follow-up study of Chinese schizophrenic patients

A cohort of 330 Chinese schizophrenic patients below age 40 were interviewed 5, 10 and 15 years later to determine which variables could predict their outcome. There were 189 males (57%) and 141 females (43%). At the end of 15 years, 48 (15%) died (34 (10%) from suicide). At the end of 5, 10 and 15 years, the percentages of patients still able to work were 55%, 54% and 48%, and still receiving treatment were 45%, 41% and 45% respectively. The patients who were well in 1990 had fewer readmissions. The only variables that consistently predicted outcome was duration of illness. Age and education level were fairly useful in predicting outcome. Sex, family history, work status, marital status, alcohol, drug and suicide history, and such symptoms as thought disorder, affective blunting, depression, delusions and hallucinations were not useful in predicting outcome.

Hospitalization patterns in schizophrenia. A 13-year follow-up

All first admitted patients in 1972 from a catchment area of 582,000 inhabitants aged 15 years or more who were diagnosed as schizophrenic at least once from 1972 until September 1983 (n = 53) were followed-up on average 13 years after first admission. About 20% of the cohort was hospitalized on any given day throughout the length of the follow-up period. The duration of hospitalization decreased from a mean of 8.2 months for the first admission to 1.7 months for the tenth or later admission. The readmission risk increased as a function of the number of previous admissions. Patients with income from occupation or from grants for education had shorter duration of first in-patient period. If the patients were diagnosed as schizophrenics already during the first hospitalization the risk for prolonged duration of the first in-patient period was increased but the readmission risk diminished. Furthermore, readmission risk after the first discharge was diminished by own income and by out-patient treatment and increased by low social status. High proportion of follow-up time in hospital (greater than or equal to 30%) was correlated to affective flattening present at first admission. Of the cohorts' total number of admissions (n = 493) 12% were involuntary. Involuntary admissions were more frequent in the first half of the follow-up period and were correlated to a previous involuntary admission.

Negative symptoms, defect state and Huber's basic symptoms: a comparison of the concepts

Comparing Crow's schizophrenia model with the defect state and Huber's basic symptoms shows that this model is an oversimplification of the complex reality of schizophrenic outcomes. The concept of negative symptoms is undermined by several factors, such as differing definitions, other confounding cross-sectional variables (e.g., akinesia and depression), short follow-ups and lack of confirmation by factorial analysis. The longitudinal concept of a defect state, which has been used in long-term follow-up studies, includes enduring symptoms currently classified as positive and negative. Huber's conceptualization of basic symptoms describes prodromal and enduring residual symptoms of schizophrenia associated with structural brain abnormalities. The overlap and lack of equivalence of these concepts and the limited empirical evidence does not allow firm conclusions. New longitudinal studies using clinical, psychosocial, and neuropsychological measures are needed to understand the natural history and etiology of the defect state.