21st Century Schizophrenics: Better Outcome? Lower Costs?
Lee, Peter W. H., Lieh-Mak, F., Yu, K. K., Spinks, J. A., Hong Kong Journal of Psychiatry
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.
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. …