Abstract
Studies assessing the treatment outcomes in first-episode schizophrenia have reported mixed results. While symptom improvement is frequently robust, when other domains are considered outcomes are generally poorer. We explored response trajectories, rates and predictors of recovery in the domains of core psychopathology, clinician-rated social and occupational functioning and patient-rated quality of life over 24 months of treatment in 98 patients with first-episode schizophrenia spectrum disorders who were treated with a long-acting antipsychotic medication. There was robust improvement in core psychopathology (effect size d = 3.36) and functionality (d = 1.78), with most improvement occurring within the first six months of treatment. In contrast, improvement in subjective quality of life was less marked (d = 0.37) and slower, only reaching significance after 12 months of treatment. Symptom remission was achieved by 70% of patients and over half met our criteria for functional remission and good quality of life. However, only 29% met the full criteria for recovery. Patients who met the recovery criteria had better premorbid adjustment, were less likely to be of mixed ethnicity and substance use emerged as the only modifiable predictor of recovery. Only 9% of our sample achieved both functional remission and good quality of life despite not being in symptom remission. We found high rates of symptom remission, functional remission and good quality of life in patients, although relatively few achieved recovery by meeting all three of the outcome criteria. Symptom remission is not a necessary prerequisite for functional remission and good quality of life, although few non-remitters achieve other recovery criteria.
Highlights
While the clinical course of schizophrenia is characterised by marked variability between individuals and over time, the overall outcome is poor for many patients.[1,2] Schizophrenia was long considered a lifelong illness with little or no hope of recovery.[3]Following the introduction of antipsychotics more than sixty years ago, treatment prospects were initially modest, with clinicians settling for outcomes such as ‘behavioural control’, ‘symptom control’, or ‘stability’.4 advances in pharmacological treatment and psychosocial interventions have heightened expectations for outcomes.[5]
Our patients responded robustly to antipsychotic treatment in terms of psychopathology improvement, with 70% achieving symptom remission. This is consistent with previous reports of a favourable treatment response in first-episode schizophrenia,[10] and suggests that when treatment is assured, the majority of firstepisode patients will achieve sustained symptom remission
While comparison of our results with those of other longitudinal studies is complicated by methodological differences, our findings are similar to others reporting poorer outcomes when domains beyond just symptom remission are considered as outcome measures.[9,10,11,12]
Summary
While the clinical course of schizophrenia is characterised by marked variability between individuals and over time, the overall outcome is poor for many patients.[1,2] Schizophrenia was long considered a lifelong illness with little or no hope of recovery.[3]. Shrivastava et al highlighted the lack of consensus for defining recovery They argue that outcome measures should be multidimensional, since social and functional improvements are not necessarily linked with antipsychotic treatment response. They emphasise that psychosocial, vocational and functional parameters differ across communities, and propose that the decision as to which components of recovery are relevant should be taken within the cultural context.[6]. The Remission in Schizophrenia Working Group (RSWG)[3] laid a foundation for the measurement of remission by operationally defining a threshold for symptom severity, with no significant interference with behaviour, for a period of at least six months These criteria are easy to apply in both clinical and research settings, and have been widely adopted. To assure treatment and circumvent nonadherence, assessments were scheduled at regular time point intervals and patients were treated with a long-acting antipsychotic medication
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