Symptomatic and Functional Recovery From a First Episode of Schizophrenia or Schizoaffective Disorder
Robinson DG, Woerner MG, McMeniman M, Mendelowitz A and Bilder RM;
Commented by , 24 Mar 2004
Aim of the study
Studies on the long-term course of schizophrenia have shown that about half of the patients recover or are only mildly impaired decades after the onset of the illness. A limitation of these studies was that they used retrospective assessments of recovery and remission.
Compared to these earlier studies the authors prospectively followed up a relatively large cohort of patients with a first episode of schizophrenia. Thus, the patients were all in the crucial early phase of the illness. In addition to rates of recovery and symptom remission they aimed to analyse predictors of recovery and whether there are different predictors for full recovery, symptom remission and adequate social functioning.
Methods
All subjects (N=118) had a first episode of schizophrenia (70%) or schizoaffective disorder (30%) and had no more than 12 weeks of lifelong antipsychotic treatment. They were assessed at baseline and then treated according to a medication algorithm. The following instruments were used for the prospective evaluations: The Schedule for Affective Disorders and Schizophrenia (SADS), the Scale for the Assessment of Negative Symptoms, a comprehensive battery to assess cognitive functions, the Social Adjustment Scale and a cranial MRI.
Full recovery (derived from the University of California at Los Angeles recovery criteria) required both – good remission of positive and negative symptoms and adequate social/vocational functioning. In addition there was a time criterion requiring that full recovery had to be achieved for two years.
Results
Patients were severely ill at baseline and were treated in the study for a mean of 221 weeks (SD=106).
47% (95% CI=36%–58%) of the subjects achieved symptom remission.
26% (95% CI=16%–35%) had adequate social functioning for 2 years or more after 5 years.
Only 14% (95% CI=6%–21%) of the patients met full recovery criteria for at least 2 years.
Only better cognitive functioning at stabilization significantly predicted all three concepts - full recovery, adequate social functioning, and symptom remission. Shorter duration of psychosis before study entry was associated with full recovery and symptom remission, but not with adequate social functioning. More cerebral asymmetry predicted full recovery and adequate social functioning. Finally, a diagnosis of schizoaffective disorder predicted symptom remission.
Discussion
The main result of the study was that some patients with first-episode schizophrenia can achieve sustained symptomatic and functional recovery, but the overall rate of recovery was low. This result was in part inexpected, because the previous more long-term follow-up studies had shown that about half of the patients achieve full recovery.
However, it must be noted that the current study examined an other stage of the disease – the first years after the onset of the disorder. Therefore, the current study rather adds to our understanding of the course of schizophrenia than questioning the results of earlier trials. It may be the case that in the first years of the illness not many patients achieve recovery and relapse frequently, whereas after decades the course improves.
In terms of predictors of recovery, the positive association of outcome with cognition, shorter duration of psychosis before treatment, cerebral asymmetry and diagnosis of schizoaffective disorder confirm previous findings.
Unexpected was the lack of association between medication discontinuation and recovery. The authors explain this lack of association by the fact that although many subjects stopped medication at some point in our study, long-term medication adherence was high.