Remission criteria and functional outcome in patients with schizophrenia, a longitudinal study

Association between social support and the severity of positive symptoms in rural community-dwelling patients with schizophrenia during the COVID-19 pandemic

BACKGROUND

This study examined the association between social support and the severity of positive symptoms in rural community-dwelling schizophrenia patients during the COVID-19 pandemic.

METHOD

The cross-sectional study included 665 rural community-dwelling schizophrenia patients investigated during the COVID-19 pandemic. Social support was measured using the Social Support Rating Scale, and positive symptoms were assessed using the Positive Scale extracted from the Positive and Negative Syndrome Scale. Multiple linear regression was adopted to examine the association of social support with positive symptoms.

RESULT

The scores for total social support, subjective support, objective support and the use of social support were 28.3 ± 5.9, 16.4 ± 5.2, 6.5 ± 1.4 and 5.4 ± 2.8, respectively. Total social support (β = -0.08, 95%CI: -0.13 to -0.02, P < 0.01) and subjective social support (β = -0.10, 95%CI: -0.16 to -0.04, P < 0.01) were significantly and negatively associated with the Positive Scale score after adjustment for confounders. Objective social support (β = 0.11, 95%CI: -0.10 to 0.32, P = 0.31) and the use of social support (β = -0.03, 95%CI: -0.14 to 0.07, P = 0.53) were not significantly associated with the Positive Scale score.

CONCLUSION

The study confirmed the importance of social support, especially subjective support, provided to rural community-dwelling schizophrenia patients during the COVID-19 pandemic. This support should be addressed and strengthened for such patients in emergent events.

Psychometric and clinical evaluation of schizophrenia remission criteria in outpatients with psychotic disorders

BACKGROUND

Psychotic disorders such as schizophrenia have debilitating effects on health and functioning. Given symptomatic remission's recent emergence as a viable treatment goal, the Remission in Schizophrenia Working Group's criteria (RSWG-cr), based on eight items from the Positive and Negative Syndrome Scale (PANSS-8), are frequently used in clinical and research settings. Against that background, we sought to evaluate the PANSS-8's psychometric properties and examine the RSWG-cr's clinical validity among outpatients in Sweden.

METHODS

Cross-sectional register data were collected from outpatient psychosis clinics in Gothenburg, Sweden. Following confirmatory and exploratory factor analyses of PANSS-8 data (n = 1,744) to assess the PANSS-8's psychometric properties, internal reliability was evaluated using Cronbach's alpha. Next, 649 of the patients were classified according to the RSWG-cr and their clinical and demographic characteristics compared. Binary logistic regression was used to estimate odds ratios (OR) and assess each variable's impact on remission status.

RESULTS

The PANSS-8 showed good reliability (α = .85), and the 3D model of psychoticism, disorganization, and negative symptoms presented the best model fit. According to the RSWG-cr, 55% of the 649 patients were in remission; they were also more likely to live independently, be employed, not smoke, not take antipsychotics, and have recently received a health interview and physical examination. Patients living independently (OR = 1.98), who were employed (OR = 1.89), who were obese (OR = 1.61), and who had recently received a physical examination (OR = 1.56) also had an increased likelihood of remission.

CONCLUSIONS

The PANSS-8 is internally reliable, and, according to the RSWG-cr, remission is associated with variables of interest for patients' recovery, including living independently and being employed. Although our findings from a large, heterogeneous sample of outpatients reflect everyday clinical practice and reinforce past observations, the directions of those relationships need to be assessed in longitudinal studies.

Neurocognition, functional outcome, and quality of life in remitted and non-remitted schizophrenia: A comparison with euthymic bipolar I disorder and a control group

There are discrepancies about if the severity of the symptomatology in schizophrenia is related to neurocognitive performance, functional outcome, and quality of life (QoL). Also, there are controversial data about the comparison between euthymic bipolar patients and different subgroups of schizophrenia in neurocognition, functioning, and QoL level. The present study aimed to compare the neurocognitive performance, functional outcome, and QoL of remitted and non-remitted patients with SC with respect to a group of euthymic patients with BD, and a control group. It included 655 subjects: 98 patients with schizophrenia in remission (SC-R), 184 non-remitted patients with schizophrenia (SC-NR), 117 euthymic patients with bipolar I disorder (BD), and 256 healthy subjects. A comprehensive clinical, neurocognitive (six cognitive domains), functional, and QoL assessment was carried out. Remission criteria of Andreasen were used to classify schizophrenia patients as remitted or non-remitted. Compared with control subjects all groups of patients showed impaired neurocognitive performance, functioning and QoL. SC-R patients had an intermediate functioning between control subjects and SC-NR, all at a neurocognitive, functional, or QoL level. There were no significant differences between SC-R and BD. These results suggest that reaching clinical remission is essential to achieve a better level of psychosocial functioning, and QoL. Likewise, the results of this study suggest that euthymic patients with bipolar disorder and patients with schizophrenia in remission are comparable at the neurocognitive and functional levels, which might have implications in the pathophysiology of both disorders.

Overlap and Mutual Distinctions Between Clinical Recovery and Personal Recovery in People With Schizophrenia in a One-Year Study

Recovery is a multidimensional construct that can be defined either from a clinical perspective or from a consumer-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. We aimed to longitudinally examine the overlap and mutual distinctions between clinical and personal recovery. Of 1239 people with schizophrenia consecutively recruited from the FondaMental Advanced Centers of Expertise for SZ network, the 507 present at one-year did not differ from those lost to follow-up. Clinical recovery was defined as the combination of clinical remission and functional remission. Personal recovery was defined as being in the rebuilding or in the growth stage of the Stages of Recovery Instrument (STORI). Full recovery was defined as the combination of clinical recovery and personal recovery. First, we examined the factors at baseline associated with each aspect of recovery. Then, we conducted multivariable models on the correlates of stable clinical recovery, stable personal recovery, and stable full recovery after one year. At baseline, clinical recovery and personal recovery were characterized by distinct patterns of outcome (i.e. better objective outcomes but no difference in subjective outcomes for clinical recovery, the opposite pattern for personal recovery, and better overall outcomes for full recovery). We found that clinical recovery and personal recovery predicted each other over time (baseline personal recovery for stable clinical recovery at one year; P = .026, OR = 4.94 [1.30-23.0]; baseline clinical recovery for stable personal recovery at one year; P = .016, OR = 3.64 [1.31-11.2]). In short, given the interaction but also the degree of difference between clinical recovery and personal recovery, psychosocial treatment should target, beyond clinical recovery, subjective aspects such as personal recovery and depression to reach full recovery.

Symptomatic Remission Along the Clinical Psychosis Spectrum: A Historical and Conceptual Review

Introduction:

In this review, a historical and conceptual panorama of symptomatic remission will be provided with a focus on the whole clinical psychosis beyond schizophrenia.

Methods:

We included all published articles on remission in psychosis, without any restrictions regarding language or year. We used a string to detect relevant articles in PubMed. We reviewed the abstracts to exclude out of scope results. Then, we evaluated the remaining articles to extract data. Variables included year of publication, language of publication, country of origin, type of article, main topic of research, main disorder studied, and reference to remission criteria.

Results:

The final dataset included 439 citations which dates back to 1950. The Remission in Schizophrenia Working Group (RSWG) criteria which was proposed in 2005 had a major effect on remission research in schizophrenia. The RSWG criteria changed the yearly published numbers of research, the main land of remission research and the scope of the articles. After 2005, the number of publications rapidly increased, and English became the primary language of the articles. Beyond prominent clinical effect, the criteria did have little impact on functional remission in schizophrenia. And also research in the last decade provided very few information about remission in other clinical aspects of psychosis spectrum including acute, transient and chronic forms. Furthermore, although there has been a conceptual unity in the last decade the heterogeneity of the studies is still far from decreasing, which still blurs the efforts to evaluate remission in psychosis.

Conclusion:

Although studies on remission in schizophrenia started in the 1950s, the criteria published in 2005 changed the whole area. However, remission discussions are not yet valid for psychotic diagnoses other than schizophrenia and are limited.

Schizophrenia outcomes in the 21st century: A systematic review

OBJECTIVE

We report a review of outcomes in schizophrenia in the twenty-first century, replicating and extending work undertaken by the late Richard Warner in his seminal book, "Recovery from Schizophrenia: Psychiatry and Political Economy" (1985;2004).

METHOD

Warner's methods were followed as closely as possible. Only observational/naturalistic studies were included. Six scientific databases were searched from 2000 to 2020. 6,640 records were retrieved. 47 met inclusion criteria.

RESULTS

Overall, complete recovery is higher in this study than in Warner's (37.75% cf 20.4%), especially for first episode psychosis (FEP) (57.1% cf 20.7%). Clinical recovery, annualized remission rate (ARR), and employment outcomes were significantly superior for first episode psychosis compared with multiple episode psychosis (MEP). ARR shows a trend toward reduction over time, from 2.2 before the financial crash of 2008 to 1.6 after (t = 1.85 df 40 p = .07). The decline is statistically significant for the MEP group (t = 2.32 df18 p = .03). There were no differences in outcome by region, sample characteristics, outcome measures used, or quality of studies. Heterogeneity of clinical outcome measures across the literature makes evidence synthesis difficult. Weak and inconsistent reporting of functional and employment outcomes mean that findings lack meaning with respect to lived experience.

CONCLUSION

Future research strategies should aim to reduce heterogeneity in clinical outcome measures and to increase the emphasis on capture and reporting of more sophisticated measures of social and functional outcome. Outcome domains should be disaggregated rather than conflated into unitary recovery constructs.

Impact of childhood trauma on positive and negative symptom remission in first episode psychosis

OBJECTIVE

Early life adversity is suspected to play an important role for onset and course of psychosis, but its relationship with longer-term clinical outcome is not entirely clear. In this longitudinal study, we investigated the impact of childhood trauma (CT) on positive and negative symptom remission in first episode psychosis (FEP) patients over two years.

METHODS

A total of 210 FEP patients were assessed with the Childhood Trauma Questionnaire. Patients reporting moderate to severe trauma (CT; N = 114; 54.3%) were compared to those without trauma (N-CT; N = 96; 45.7%). Positive (PSR) and negative symptom remission (NSR) were determined monthly over 24 months following established criteria using the Scale for Assessment of Positive Symptoms and the Scale for Assessment of Negative Symptoms. Global Functioning was evaluated at baseline and 24 months of follow-up.

RESULTS

Compared to N-CT patients, CT patients had achieved significantly lower rates of PSR at 12 months and significantly lower rates of NSR at 24 months. A dose-response relationship was observed between the number of trauma categories fulfilled and the number of patients not achieving PSR and NSR at these time points. Higher trauma scores were significantly associated with poor functioning and higher positive and negative symptom severity at 24 months, but not at baseline and 12 months of follow-up.

CONCLUSION

Differential effects of CT on clinical outcome may not be apparent at psychosis onset, but only become evident through poor symptomatic remission and general functioning over time. Targeted diagnostic and therapeutic efforts after illness onset might limit these detrimental consequences.

Validation of a four items version of the Functional Remission of General Schizophrenia scale (the mini-FROGS) to capture the functional benefits of clinical remission

Objectives

We previously developed the Functional Remission Of General Schizophrenia (FROGS) scale demonstrating first, reliable assessment in a cross-sectional study and second, good time-stability. The purpose of the present analysis was to propose a shorter version (mini-FROGS), more compatible with the limited time available in a psychiatric visit, focusing on the functional domains that have higher likelihood of being improved with higher and/or longer symptomatic remission in different cultural backgrounds.

Methods

We used multiple regressions to find the most informative items explaining increased length of symptomatic remission, using prospective data from a national observational multicenter survey. Then, the mini-FROGS was used in different European countries to test its between-center reliability, compared to other scales.

Results

Four domains were retained as capturing the maximum of symptomatic remission, namely (1) travel and communication, (2) management of illness and treatment, (3) self-esteem and sense of independence and (4) respect of biological rhythms. First, the mini-FROG was evaluated in 443 French patients with clinical remission and 22 without, and 12/18 months later in 140 patients still in clinical remission and 23 in relapse. In Europe, 295 schizophrenia patients were assessed with the mini-FROGS and other scales devoted to functional remission, allowing comparisons. The mini-FROGS showed good correlations with other scales in different countries and demonstrated good psychometric properties.

Conclusion

These results give evidence that a 4 items-only version of the FROGS scale may be useful to assess important aspects of functional remission, tightly linked to the length of clinical remission.

Remission in schizophrenia - What are we measuring? Comparing the consensus remission criteria to a CGI-based definition of remission and to remission in major depression

BACKGROUND

Despite being recommended for use in clinical trials, the consensus remission criteria were found to leave patients with persisting symptoms, relevant areas of functional impairment and a decreased sense of wellbeing. Therefore, to evaluate the appropriateness of the schizophrenia consensus criteria, a definition of remission based on the Clinical Global Impression Scale (CGI) was developed and remitter subgroups were compared.

METHODS

239 patients with a schizophrenia spectrum disorder were evaluated regarding their remission status after inpatient treatment. Remission in schizophrenia was defined according to the symptom-severity component of the consensus criteria by Andreasen et al. and a CGI based definition was calculated using sensitivity and specificity using receiver operating curves (asymptomatic remitter). Both remitter groups (schizophrenia consensus versus asymptomatic remitters) were compared regarding different clinical variables at discharge as well as the likelihood to relapse within a 1-year follow-up period. Both schizophrenia remitter subgroups were compared to remitters in major depression as a reference value.

RESULTS

Following the consensus criteria, 63% of the schizophrenia patients were in remission compared to only 18% following the asymptomatic criterion. The schizophrenia consensus remitters were less likely to be concurrent treatment responders (p < 0.0001), had a significantly greater illness severity (p < 0.0001) and less functioning (p = 0.0358) as well as a significantly greater risk to relapse (p = 0.0174) compared to the schizophrenia asymptomatic remitters as well as the depressed remitters.

CONCLUSION

It should be critically re-evaluated if the currently proposed consensus criteria are adequate to measure what is traditionally understood to be remission.

Longitudinal evidence for a relation between depressive symptoms and quality of life in schizophrenia using structural equation modeling

Patients diagnosed with schizophrenia often report a low quality of life (QoL). The purpose of this study was to investigate whether we could replicate a cross-sectional model by Alessandrini et al. (2016, n = 271) and whether this model predicts QoL later in life. This model showed strong associations between schizophrenia spectrum symptoms and depressive symptoms on QoL, but lacked follow-up assessment. This model was adapted in the current study and the robustness was investigated by using a longitudinal design in which the association between baseline variables (including IQ, depression, schizophrenia spectrum symptoms as well as social functioning) and QoL during 3-years of follow-up was investigated. We included patients with a non-affective psychotic disorder (n = 744) from a prospective naturalistic cohort-study. In the cross-sectional model, with good measure of fit, both depression as well as social functioning was associated with QoL (direct path coefficient -0.28 and 0.41, respectively). Additionally, the severity of schizophrenia spectrum symptoms was highly associated with social functioning (direct path coefficient -0.70). Importantly, the longitudinal model showed good measures of fit, which strengthens the validity of the initial model and highlights that depression prospectively affect QoL while schizophrenia spectrum symptoms prospectively influence QoL via social functioning. The negative, longitudinal impact of a depression on QoL highlights the need to focus on treatment of this co-morbidity.

Gender differences in childhood trauma in first episode psychosis: Association with symptom severity over two years

Early life adversity is associated with increased risk for psychosis onset and poor clinical outcome. Male compared to female patients often show a more severe course of psychotic illness. The aim of the present study was to investigate gender differences in childhood trauma (CT) and their impact on symptomatic and functional outcome following psychosis onset. The study included 210 patients (144 men, 66 women) diagnosed with a first-episode of psychosis (FEP). Early adversity was assessed with the Childhood Trauma Questionnaire. Psychotic symptoms and general functioning were rated with the Brief Psychiatric Rating Scale and Global Assessment of Functioning scale at baseline, 12 and 24 months of follow-up in an established early intervention service. Male patients reported higher rates of physical or emotional neglect, whereas female patients indicated significantly higher rates of emotional abuse. More severe CT was related to higher levels of depression in women and to negative symptoms in men. Distinct CT effects were observed on positive and negative symptom severity and global functioning in male patients at 24 months. Emotional abuse was the strongest predictor of depression in both genders. In male patients only, emotional abuse predicted positive symptom severity and impaired global functioning, whereas emotional neglect predicted more severe negative symptoms. Our results suggest differences in CT experiences in male and female FEP patients, with a more pronounced impact on longer-term outcome in male patients. The findings support the notion that sex differences in stress vulnerability account for the relatively poor illness course in male psychosis patients.

Symptomatic remission in schizophrenia: Results from a risperidone maintenance treatment study

This study aimed to investigate remission following the treatment of schizophrenia patients with risperidone. Clinically stabilized patients with schizophrenia (n = 374) were randomly assigned to 4-week, 26-week, or no-dose-reduction groups, in which the baseline risperidone dose was continued for 4, 26, or all weeks during 1-year period. The 'Positive and Negative Syndrome Scale' (PANNS) was assessed at baseline and monthly for six months, followed by every two months until the last recruited patient completed 1-year follow-up. Symptomatic remission was defined according to criteria established by the Schizophrenia Working Group. A Generalized Linear Mixed Model indicated significant variation in remission over time, which increased after baseline in the entire group (F = 49.32, df = 1, 3114, P < 0.001). The overall length of risperidone treatment (F = 4.34, df = 1, 416, P = 0.038) and the duration of illness (F = 8.51, df = 1, 359, P = 0.004) had significantly negative effects upon remission. Baseline remission patients were associated with a significantly increased time to relapse compared with the baseline of non-remission patients over a one year follow up period (F = 5.74, df = 1, 367, P = 0.017). One-year risperidone maintenance treatment increased remission rates in schizophrenia. A shorter illness duration, risperidone treatment length, and a lower total PANSS score were clinically useful predictors of remission. Achieving remission may postpone relapse.

Psychosocial functioning in relation to symptomatic remission: A longitudinal study of first episode schizophrenia

OBJECTIVES

The aims of the study were: (1) to evaluate longitudinally symptomatic remission in first-episode (FE) schizophrenia, (2) to describe symptoms, social functioning and quality of life (Qol) in relation to remission status, and (3) to determine the long-term outcome of schizophrenia and its early predictors.

METHODS

Sixty-four patients were assessed 1 month after a first hospitalization (T1), 12 months (T2), 4-6 years (T3), and 7-11 years (T4) after T1. The patients were allocated to three remission groups according to their remission status over the whole observation period, e.g. stable remission (SR), unstable remission (UR) and non-remission (NR). The PANSS, Social Functioning Scale and WHOQoL were used to evaluate the patients' psychosocial functioning levels, symptomatic and functional remissions and satisfying QoL. A good outcome was defined as meeting, simultaneously, the criteria of symptomatic and functional remissions and satisfying QoL at T4, while failure to meet all of these criteria was defined as a poor outcome.

RESULTS

Among them, 17.2% patients were in stable remission, 57.8% in unstable remission and 25.0% were unremitted at all time points. The SR group had lower levels of psychopathological symptoms and reported better social functioning and QoL than the NR group. During the follow-up, the symptoms increased, social functioning slightly improved and QoL did not change. At T4, 53% of the sample had a poor outcome, which was independently predicted by the longer duration of untreated psychosis and a lack of satisfying QoL at T1.

CONCLUSIONS

Our results demonstrate that: (1) the long-term course in schizophrenia is heterogeneous and that three illness trajectories exist, (2) social functioning and QoL are only partially connected with symptomatic remission (3), the risk of a poor outcome may potentially be reduced by appropriate interventions at an early stage of the illness.