21st Century Schizophrenics: Better Outcome? Lower Costs?

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SUMMARY

The recent literature on schizophrenia generally points to a better outcome and a more benign metamorphosis in the schizophrenic illness process. We report a study on the cross-sectional outcome of 153 actively follow-up schizophrenic patients in Hong Kong. Apart from their more favourable symplomatic outcome, other outcome indicators relating to social relationship, quality of life, and work adjustment can hardly be labelled as benign. Results obtained from the one year follow-up on the same group of subjects indicated that symptomatic control was less consistent and liable to fluctuate over time. Other psychosocial measures of outcome were, however, highly consistent and stable over time. This Indicated that psychosocial handicaps associated with schizophrenia may be more resistant to our currently emphasized forms of treatment. The rehabilitation cost of sustaining schizophrenic patients in society is discussed in relation to the present outcome pattern, and implications for future directions in the management of schizophrenia in a more cost effective manner'is proposed.

INTRODUCTION

Schizophrenia in !he 21st century promises an increasing optimism than ever before known Indeed, a benign metamorphorsis (Zubin et al., 1983) in the pathological process was postulated. Lehmann (1981) estimated that the chances of a favourable schizophrenic outcome are four to fine. times better than they were in the early years of the century. Kraepelin originally regarded inevitable deterioration into a typical "end-state" as the defining criterion for dementia praecox. He subsequently revised has estimate to a lower 70% for ultimate deterioration. Based on their earlier survey of 800 outcome studies and also reviewing the results of other follow-up studies conducted in Europe, Zubin et al, (1983) asserted chat " ... the outcome of schizophrenia appears to be changing from chronicity to an episodic course with a more favourable outlook." Wing (1987) also cautioned that the pessimistic schizophrenic outcome may be complicated by the poverty of the social environment.

Manfred Bleuler (1978) categorised 6%-15% of his long term follow-up probands as persistently chronic. He argued flat schizophrenia. was not a generally deteriorating condition, particularly after the fast five years. His data indicated that about 25i4 of shlozophrenic patients would recover completely with no further need for treatment. An intermediate group comprising about half of the patients would for a fluctuating course for years depending on environmental and treatment factors. Of the remaining 25%, only 10% would result in permanent hospitalisation or become invalidated for life. Bleuler also rioted a general improvement in the schizophrenic course due to improvement in a social and environmental conditions predating the phenothiazine era. In line with this general expectation. other studies provided a similary positive outlook for schizophrenic outcome (Ciompi, 1980; W.H.O., 1979; Lo and Lo, 1977). Strauss et al. (1978) compared the two year outcome of a group of schizophrenic with non-schizophrenic. psychiatric patients, and noted that "although there was a trend toward the schizophrenics being worse on all outcome measures, there were no significant differences between the two groups on measures of social relationships, work functioning, and symptom severity at follow-up". Studies in Berlin by Pietzcker and Gaebel (1987) supported some of Strauss et al's (1978) findings that by the end of their first year of follow-up. schizophrenic patients did not differ significantly in a number of clinical outcome measurements from their control patents with neurotic and affective disorders.

Despite the gradually unfolding consensus pointing towards a more benign outcome in schizophrenia, the concept of outcome employed in previous studies had mostly been unclear. This problem was confounded by the use of nonspecific and non-operationally defined criteria. Instead of specifying outcome dimensions in different aspects of the patient's life function, global descreptive terms like improved", "unchanged" or "unimproved" were used. Fallon (1983) noted that "the increasingly rigorous attention paid to the diagnosis of schizophrenia has not yet been extended to the development of reliable and valid criteria for describing the course of the illness." Indeed recent findings Indicated that outcome was unlikely to be classifiable under global and vaque descriptive categories. Ciompi (1980) noted that "there is no such thing as a specific course of schizophrenia". Strauss and Carpenter's group (1972, 1974a, 1974b) argued that outcome in schizophrenia was characterised by a highly variable and heterogenous proccess. Bleuler (1974) noting the wide variety of outcomes in schizophrenic patients was convinced that "a specific treatment of schizophrenia does not exist". Falloon (1983) cautioned that "successful management of an illness should effectively minimize all symptoms of the condition and any associated. disability and handicap". Studies in schizophrenic outcome seemed to be reminiscent. of Rachman's (1974) concept of "desynchrony" between different outcome parameters in anxiety neurotics. indicating that multi-dimensional treatment approches may be needed to totally combat the incapacitating effects of the illness

A clear and operational delineation of specific outcome criteria became all the more important given that there was only a moderate relationship between outcome measures on hospitalisation, social contracts, employment status, and symptomatology (Strauss et al,. 1972). Inter-relationship between different outcome measures accounted only for 7% to 14% of the total variance, Strauss and his colleagues concluded that " ... schizophrenic outcome is a mixture of some general factor affecting the level of all functions, together with considerable individual variation of the separate areas". This failure to acknowledge the varying characteristics of outcomes and disparate courses within the Schizophrenic disorder tended to add to the existing confusion and misconception regarding its pathologicial nature. Rather than holding on to a global feeling of optimism, a better understanding of the more benign versus the more resistant incapacities of The schizophrenic patient becomes a vital step for better resource allocation in this area.

This research report deals with the application of a set of operationally definable criteria for studying outcomes in schizophrenic patients in our local Hong Kong Chinese setting. The outcome pattern of 153 schizophrenic subject is reported. A clearer demarcation of the more benign symptoms compared with the more resistant handicaps resulting from the schizophrenic illness is also attempted. The issue …