Editorial
Longitudinal Studies of Outcome and Recovery
in Schizophrenia and Early Intervention:
Can They Make a Difference?
Martin Harrow, PhD 1,
Thomas H Jobe, MD2
Knowledge about typical course and outcome are valuable for a better understanding of any disorder. In schizophrenia, it is particularly important, since some key concepts of this disorder involve views about its course and outcome. The concept of schizophrenia is linked to early views of a chronic disorder and a decline in functioning, or at least very poor outcome.
Thus schizophrenia was once viewed by Kraepelin, who pioneered the concept of dementia praecox, as a disorder with a progressive downhill course (1). Bleuler’s later, somewhat more optimistic outlook, still viewed some aspects of psychopathology in schizophrenia as always present, although in reduced form at times (2).
If these older, more pessimistic views are examined from a contemporary standpoint, several issues arise. One is whether potential intervals or periods of recovery, and even potential long-term recovery, are frequent in schizophrenia. Despite the earlier pessimistic views, recent longitudinal studies have produced evidence that some, or many, schizophrenia patients do experience periods or intervals of recovery (3–5). However, the answer to how many or what percentage of patients have this potential still awaits further research. Among the many issues that longitudinal research in this area has raised is the question of whether long-term outcome and potential recovery in schizophrenia now differ from outcomes prior to our era of modern treatment and rehabilitation (6). This is the type of issue that can be approached with longitudinal research.
Is knowledge about outcome and potential periods of recovery in schizophrenia of any other importance? For several different reasons, there have been affirmative suggestions in regard to this question. As one researcher has pointed out in relation to the value to schizophrenia patients of a more optimistic prognosis, “If you don’t know where you should try to go (improvement and recovery), you may never get there” (7). This comment can apply equally well to mental health professionals treating or helping patients with schizophrenia. Aspects of our own longitudinal research program (5,8) and other research programs (3,9) indicate that, while many patients with schizophrenia have poor outcomes, a subgroup of these patients are able to experience intervals or periods of recovery, leave treatment, and leave the mental health system for a period of time.
What factors are associated with periods of recovery, and what factors can contribute even further to recovery? Evidence from our research and that of others indicates a combination of the following: initial treatment with antipsychotics to reduce psychosis; other, even earlier factors, such as early interventions to diminish the probability of the emergence of more flagrant psychosis, as discussed by Malla and colleagues in this issue (10); and a third, very important, element. This third element is the influence of protective factors that are related to these patients’ own internal resources (including the skills involved in their own premorbid developmental achievements) and that facilitate their later periods of recovery. With regard to inner resources, we must remember that not all schizophrenia patients are alike. For the subsample of patients with schizophrenia who show periods of recovery, some periods last for 1 or 2 years, and others last for 6 or more years. While we now have evidence of periods of recovery in some (but not all) patients with schizophrenia, considerably more research is needed on what factors, other than routine treatment and possible early interventions, are most likely to make a difference in patients’ lives. This includes further evidence both on factors that may facilitate potential recovery and on factors that are more likely to contribute to relapses. Contemporary research on expressed emotion and potential factors involved in it (such as possibly living in disapproving and anxiety-arousing settings) represents one example of research on factors that can make a difference in some patients’ lives (11,12). Overall, precise knowledge of course, outcome, and the potential for recovery is particularly important not only for our basic understanding of the concept of schizophrenia but also to provide additional guidelines for efforts toward treatment, rehabilitation, and long-term recovery (13,14).
In this issue, we focus on current evidence concerning very long-term outcome in schizophrenia and on one very important approach to improving course and outcome, namely, early intervention programs. In regard to the first of these topics, Jobe and Harrow review a series of long-term studies on outcome in present-day schizophrenia (15). These outcome studies employ different methodologies, different techniques, and different sample types. They are obviously not flawless studies, but when one combines them, certain consistencies in the results begin to appear. The second series of studies, reviewed in this issue by Malla and colleagues (10) focus on early intervention programs and short-term outcome associated with these programs. They view multiple aspects of short-term outcome, including clinical outcome, relapse, quality of life, and community, social, and vocational functioning.
Overall, the long-term studies of outcome in schizophrenia reviewed by Jobe and Harrow provide clear indications that present-day schizophrenia is still a poor-outcome disorder, compared with other psychotic and nonpsychotic disorders (5,16). Nevertheless, despite this, there are reasons for optimism. There is clear evidence that patients with schizophrenia do not deteriorate over time; moreover, most do not have continuous psychotic symptoms. Rather, the evidence is beginning to suggest that, with contemporary treatments, including rehabilitation programs, some patients enter into periods or episodes of recovery. The possibility also exists that, as they approach old age, many may show some improvement. Again, these are issues that can be approached with longitudinal research.
Fortunately for the field, consumer organizations such as the National Alliance for the Mentally Ill (NAMI), and others, have been urging funding agencies to take steps to enhance services for schizophrenia patients and to support research on schizophrenia. This includes research that will begin to provide answers to some of the basic questions related to outcome in schizophrenia and to potential recovery from this disorder as well as to the potential of early interventions for improving outcome. In recent times, consumer organizations have become an important factor in the mental health picture, and this is a constructive development. The mobilization and support of consumer groups can be a valuable asset in efforts to fund services designed to improve outcome and facilitate research that studies the processes involved in improvement and recovery over time. Many of these efforts are not designed specifically for follow-up studies or early intervention studies. However, long-term follow-up studies that focus on outcome, and especially potential recovery and factors involved in it, as well as studies of early interventions designed to improve outcome, do fit within the broad goals toward which several consumer organizations are striving.
References
1. Kraepelin E. Dementia praecox and paraphrenia (1919). New York: Robert E Krieger Publishing Company Inc; 1971.
2. Bleuler E. Dementia praecox or the group of schizophrenias (1911). New York: International Universities Press; 1950.
3. Fenton W, McGlashan T. Sustained remission in drug-free schizophrenic patients. Am J Psychiatry 1987;144:1306–9.
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5. Harrow M, Grossman L, Jobe T, Herbener E. Do patients with schizophrenia ever show periods of recovery? A 15-year multi-follow-up study. Schizophr Bull 2005;31:723–34.
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11. Falloon I, Boyd JL, McGill CW, Williamson M, Razani J, Moss HB, and others. Family management in the prevention of morbidity of schizophrenia. Clinical outcome of a two-year longitudinal study. Arch Gen Psychiatry 1985;42:887–96.
12. Hooley J, Gotlib I. A diathesis-stress conceptualization of expressed emotion and clinical outcome. Applied & Preventive Psychology 2000;9:135–51.
13. Malla A, Norman R, Manchanda R, Ahmed R, Scholten D, Harricharan R, and others. One year outcome in first episode psychosis: influence of DUP and other predictors. Schizophr Res 2002;54:231–42.
14. Stephens J, Pascal R, McHugh P. Long-term follow-up of patients hospitalized for schizophrenia, 1913–1940. J Nerv Ment Dis 1997;185:715–21.
15. Jobe TH, Harrow M. Long-term outcome of patients with schizophrenia: a review. Can J Psychiatry 2005;50:892–900.
16. Winokur G, Tsuang M. The natural history of mania, depression, and schizophrenia. Washington (DC): American Psychiatric Press; 1996.
Author
1. Professor and Director of Psychology, Department of Psychiatry, University of Illinois College of Medicine, Chicago, Illinois.
2. Professor of Psychiatry, Department of Psychiatry, University of Illinois College of Medicine, Chicago, Illinois.
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