Standardized remission criteria in schizophrenia

Abstract

The clinical overview article with this title, by Van Os et al., introduces standardized criteria for remission to a European audience. As the article states, and as implied by the criteria, the time has come to shed pervasive pessimism about the outcome of schizophrenia and to recognize that it is not inevitably a chronic illness that leads to a deteriorating course in all patients. Instead, we must begin to identify subgroups within this heterogeneous disorder that have a differential course and outcome. This concept has been present for many years as ‘the rule of thirds’: one-third improve, one-third deteriorate, and one-third have an intermediate course. But the rule of thirds had no empirical basis. Having criteria for symptomatic remission is the first step that will permit us to base our predictions about course on empirical evidence. The first early studies by Lasser et al. and Van Os et al., not as yet published, confirm that approximately one-third of patients can indeed achieve symptomatic remission based on standard criteria. This type of work is just the beginning. We continue to confront many challenges as we attempt to understand and treat schizophrenia. For example, once we define groups based on outcome, we need to characterize them. What are the best predictors, assessed at the beginning of the illness or intake into a clinical trial, of a good vs. poor outcome? Symptom severity? Specific groups of symptoms, such as negative symptoms? IQ? Other cognitive measures? Premorbid function? Availability of social supports? Treatment received? Treatment side effects? Indicators of drug metabolism, such as cytochrome P450? Neural measures based on structural and/or functional imaging? Any of the genomic measures that are just emerging, such as dysbindin, catechol-o-methyl transferase, or brain derived neurotropic factor? How does improvement or impairment in psychosocial and cognitive function correlate with symptomatic remission? The needs and opportunities are almost endless. The long-term goal of the ‘remission criteria’ initiative is to find better ways to treat people who suffer from schizophrenia. In a more ideal world, and within our reach within the next decade, we will be able use a host of scientific and empirical tools to select the best treatment for an individual patient, based on measures of the type described above. This strategy offers hope rather than pessimism. It bases clinical decisions on evidence rather than guess-work. It replaces a shot-gun approach with a surgical approach to treatment decisions. Defining outcome criteria is the first step necessary to implement this strategy.