Schizophrenia, an Illness with Bad Outcome: Myth or Reality?

Article excerpt

Objective: Different myths about schizophrenia endorsed by clinicians maintain the pessimism about outcome thus reducing chances of improvement. There are no recent North American studies on the long-term outcome of first-episode schizophrenia to clarify if these beliefs are myths or reality. Our study describes the long-term outcome (10 to 16 years) of a first-episode schizophrenia incidence cohort (n = 142) in a Canadian urban centre between 1983 and 1999.

Method: Clinical and social functioning at different time points were assessed retrospectively from medical files of a catchment area hospital in Montreal. Service use and deaths were noted from provincial databases of physician billings, hospitalization, and vital statistics.

Results: Hospitalization days decreased considerably after the first year, with a small minority still needing it episodically after 4 years. Marital and occupational status were generally stable over time, but autonomy in living arrangements worsened. Thirty-three percent of subjects quit the Catchment Area Specialized Psychiatric Services. This group showed better social functioning while they were followed, were hospitalized less afterwards, and had fewer suicides, therefore indicating a better outcome for them. At the end of our study, 15% of the patients still alive were well enough to function without seeking medical help and 25% were not taking antipsychotic medication. Better outcome was predicted by older age at admission, being married, higher premorbid autonomy in living arrangements, and female sex.

Conclusion: A significant proportion of first-episode schizophrenia patients achieve moderate long-term outcome, and the stability of global functioning is more frequent than deterioration, as shown in most industrialized countries.

Can J Psychiatry. 2011;56(2):92-101.

Clinical Implications

* The heterogeneity of outcome widens as duration of follow-up increases, and a proportion of schizophrenia patients might function without long-term medication.

* Occupational deficit stability suggests it should be the target of early intervention programs to prevent significant deterioration of functioning and of later supported employment rehabilitation approaches.

* The decline in autonomous housing suggests early supported housing in the community, in collaboration with relatives, when patients move from their parents' home.

Limitations

* Our sample covered most of the catchment-area incident schizophrenia patients, but was limited to patients hospitalized at least once.

* The functioning of a proportion of subjects could not be assessed until study end, but many of them were functioning without seeking medical help.

* No symptomatology measures were included, therefore no correlations could be made between symptoms and functioning.

Key Words: first-episode schizophrenia, predictors, epidemiology, functioning, long-term outcome

Despite recent developments in psychopharmacology and psychosocial treatments, several myths about schizophrenia

. . . maintain the pessimism about outcome for these patients thus significantly reducing their opportunities for improvement and/or recovery ... the 'clinician's illusion' . . . occurs when clinicians repeatedly see the few most severely ill in their caseloads as 'typical' when in fact such patients represent a small proportion of the actual possible spectrum.1· p l4(l

Longitudinal studies are key to understanding the evolution of schizophrenia and the factors influencing its course. Hegarty et al2 reported an increase in the proportion of subjects showing improvement after 6 years, in the second (48.5%) compared with the first half (35.4%) of the 20th century. All of these investigations did not meet the quality criteria proposed by Hafner:

The beginning of the follow-up period should be comparable across the study cohort and as close to illness onset as possible . …