Recovery from psychotic illness: a 15- and 25-year international follow-up study.

BACKGROUND: Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia. AIMS: To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables. METHODS: Historic prospective study. Standardised assessments of course and outcome. RESULTS: About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery. CONCLUSIONS: A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Long-term trends of symptoms and disability in schizophrenia and related disorders.

BACKGROUND: Relatively few studies describe the long-term course of schizophrenia in well-defined cohorts of patients assessed soon after the illness onset. The aim of this paper is to describe the overall trend of schizophrenia in a 16-year follow-up study of patients and to explore the predictive value of several variables measured at the time of inclusion in the study. The course of the disorder is described along both a 'clinical' and a 'social' dimension. METHODS: The sample of 60 patients with a recent onset of a non-affective psychosis was first assessed in 1978-1980 as part of the study, coordinated by the WHO, on Reduction and Assessment of Psychiatric Disability. Data from the last follow-up are used to rate the overall trends of psychotic symptoms and of social disability. Based on a subdivision of the follow-up period into three sub-periods, the trend for the patients is rated for each of the two dimensions as improvement, deterioration, and no change or fluctuating. The associations of these trends with several predictor variables (age at onset, gender, martial status, education level, family history of mental illness, type of illness onset, personality assets) are explored by cross-tabulation (with calculation of the relative risk) and by a logistic regression model. RESULTS: The predominant pattern for psychotic symptoms is improvement (55% of the subjects), while the predominant pattern for social disability is deterioration (45% of the subjects). A trend of improvement of psychotic symptoms correlated significantly with a negative family history of severe psychiatric disorder and with an acute type of illness onset. Only the first variable entered the logistic regression model. A trend of improvement of social disability correlated significantly with gender, marital status, presence of personality assets, and type of illness onset. All of these predictors entered the logistic regression model, with the exception of marital status; age at onset also entered the logistic regression. CONCLUSIONS: Psychotic symptoms and social disability are relatively autonomous descriptors of the course of schizophrenia. A speculative hypothesis is that symptom course is more closely related to innate factors, while social disability is contingent upon the acquired level of personal and social competence at the time of illness onset. Future studies are needed to assess the effects of psychiatric interventions that could ameliorate the long-term prognosis of social disability in patients with schizophrenia.

Social disability in schizophrenia: its development and prediction over 15 years in incidence cohorts in six European centres.

BACKGROUND: This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts. METHODS: Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule. RESULTS: Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years. CONCLUSION: Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.

A 16-year follow-up study of schizophrenia and related disorders in Sofia, Bulgaria.

A total of 60 patients with functional non-affective psychoses were assessed 16 years after their inclusion in the WHO co-ordinated study on reduction and assessment of psychiatric disability. All patients at inclusion had a recent onset of a psychotic disorder. About one-third of the patients had a good outcome. The rest showed moderate to severe psychiatric symptoms and social disability. Comparison with other similar studies suggested that our results show a low mortality rate, high levels of clinical symptoms, high levels of social disability and a low percentage of institutionalized patients. These findings are discussed in the context of the high level of family involvement in patients' care, which could reflect a cultural factor.