What Courses and Outcomes are Possible in Schizophrenia?

Abstract

Kraepelin described one of the core features of schizophrenia to be its progres­sively worsening course with little chance of recovery. In contrast, mood dis­orders were thought to have an episodic course with good functioning between bouts of mania and depression, and a relatively good outcome. The ensuing dec­ades of research have painted a more complex picture of the course and outcome of schizophrenia. Most notably, in contrast to Kraepelin’s bleak outlook, a fair number of individuals can more or less successfully recover from schizophrenia. Dr Manfred Bleuler, son of Dr Eugen Bleuler, reported a 20- year follow-up of over 200 individuals with schizophrenia excluding those who had either died or shown little psychiatric stability over the previous 5 years. Bleuler noted that one in five patients had recovered to normal levels of social functioning and were free of psychotic symptoms. Furthermore, one in three patients had a relatively good outcome. Thus, while patients still experienced hallucinations and delu­sions, they showed only mild problems in social functioning and very few visible behavioural problems. These results are quite remarkable given that the study was completed prior to the discovery of antipsychotic medications.Dr Luc Ciompi was able to follow nearly 300 patients for as long as 50 years after hospitalization. Using Bleuler’s categories of outcome, Ciompi found 27% of the patients to be fully recovered, 22% to have mild symptoms, 24% to have moderately severe symptoms, and 18% to have severe symptoms. Nine per cent of the sample had an uncertain outcome. A progressively worsening, gradual, and serious onset was seen in about half of the affected individuals, while a sudden or acute onset of illness with little or no problems in premorbid func­tioning was found for the rest of the sample. About half of the individuals with schizophrenia had a continuous course of illness, and the remainder had an episodic course. In addition, an episodic course was more likely among patients with acute onset. Acute onset and episodic course were both associated with better long- term outcome.A study performed by Dr Ming Tsuang and team, known as the Iowa 500 study, followed 186 individuals with schizophrenia, 86 with bipolar disorder, and 212 with major depressive disorder for 35– 40 years.