Transcript Slide 1

Schizophrenia
Outcome and Prognosis
Dr Antonio Metastasio
[email protected]
Schizophrenia
the concept of psychosis and of
schizophrenia evolved in the last two centuries
The progress of Psychiatry and a better
understanding of the illness changed the view
of schizophrenia
The outcome of schizophrenia is highly
heterogeneous
better consider the outcome as a continuum
Tandon et al., 2009
Both Kraepelin and Bleuler believed that schizophrenia is a disorder that
lead inexorably to deterioration.
However both recognized that the course of the disease can be
interrupted by remissions of greater or lesser completeness which can
last days, weeks, years or decades
One hundred years of schizophrenia: a meta-analysis
of the outcome literature
METHOD: Meta- analysis of the international literature on outcome in
schizophrenia or dementia praecox from 1895 to 1992 identified 821 studies;
320 of these, with 51,800 subjects in 368 cohorts, met the inclusion criteria for
the study.
RESULTS: Only 40.2% of patients were considered improved after follow-ups
averaging 5.6 years. Outcome was significantly better when patients were
diagnosed according to systems with broad criteria (46.5%) or undefined
criteria (41.0%) rather than narrow criteria (27.3%). The proportion of
patients who improved increased significantly after mid- century (for
1956-1985 versus 1895-1955, 48.5% versus 35.4%), probably reflecting
improved treatment as well as a broadened concept of schizophrenia.
However, in the past decade, the average rate of favourable outcome has
declined to 36.4%, perhaps reflecting the re- emergence of narrow diagnostic
concepts.
CONCLUSIONS: Overall, less than half of patients diagnosed with
schizophrenia have shown substantial clinical improvement after follow-up
averaging nearly 6 years. Despite considerable gains in improvement rates
after mid- century, there has been a decline since the 1970s.
Hegarty et al., 1994
One hundred years of schizophrenia: a meta-analysis
of the outcome literature
Outcome
60%
50%
40%
30%
20%
10%
0%
1895 -1955
1956 -1985
period
Hegarty et al., 1994
Van Os & Kapur 2009
Van Os & Kapur 2009
Niendam et al., 2009
Natural history of schizophrenia
“acute phase,” characterized by florid psychosis and severe positive
and/or negative symptoms, is followed by a
“stabilization phase,” during which symptoms recede and decrease in
severity, and a subsequent
“stable phase” with reduced symptom severity and relative symptom
stability. According to these guidelines, “the majority of patients
alternate between acute psychotic episodes and stable phases with full
or partial remission”
APA 1997
Tandon et al., 2009
remission
…a state in which patients have experienced an improvement in core signs
and symptoms to the extent that any remaining symptoms are of such low
intensity that they no longer interfere significantly with behaviour and are
below the threshold typically utilized in justifying an initial diagnosis of
schizophrenia.
Andreasen et al., 2005
Definition of response and remission
When the Brief Psychiatric Rating Scale (BPRS) or the Positive and
Negative Syndrome Scale (PANSS).
 A cut-off of at least 50% reduction of the baseline score should be used for
acutely ill, non-refractory patients.
A cut-off of at least 25% reduction for refractory patients.
Leucht et al., 2009
Good prognosis VS bad prognosis
Sudden onset
VS
Insidious onset
Good prognosis VS bad prognosis
Short episode
VS
long episode
Good prognosis VS bad prognosis
No past psychiatric history
VS
past psychiatric history
Good prognosis VS bad prognosis
Prominent affective symptoms
VS
Negative symptoms
Good prognosis VS bad prognosis
Female gender
VS
Male gender
Good prognosis VS bad prognosis
Older age of onset
VS
Younger age of onset
Good prognosis VS bad prognosis
Married
VS
Single, separated, widover
Good prognosis VS bad prognosis
Normal neuroimaging
VS
Enlarged lateral ventricles
Good prognosis VS bad prognosis
Good psychosexual adjustment
VS
Bad psychosexual adjustment
Good prognosis VS bad prognosis
Good social relationship
VS
Social isolation
Good prognosis VS bad prognosis
Good compliance
VS
Poor compliance
Good prognosis VS bad prognosis
Normal premorbid personality
VS
Abnormal premorbid personality
Good prognosis VS bad prognosis
Normal IQ/no cognitive deficits
VS
Lower IQ/cognitive deficits
Good prognosis VS bad prognosis
No Alcohol & Substance misuse
VS
Alcohol & Substance misuse
Good prognosis VS bad prognosis
Normal Expressed emotions
VS
High expressed emotions
Good prognosis VS bad prognosis
No family history/genetic risk
VS
Family history/genetic risk
Good prognosis VS bad prognosis
Duration of Untreated Psychosis (DUP)
Short DUP
VS
Long DUP
Association Between Duration of Untreated Psychosis
and Outcome in Cohorts of First-Episode Patients
(DUP) and
outcomes by
follow-up point.
Marshall et al., 2005
Association Between Duration of Untreated Psychosis
and Outcome in Cohorts of First-Episode Patients
Odds of no remission in the long vs short DUP groups.
Marshall et al., 2005
Early intervention service
Implications for practice
1. For people presenting with prodromal symptoms of psychosis.
At the moment it is not clear whether treating people presenting with prodromal
symptoms of schizophrenia provides any benefits. There is insufficient data on
the personal and social consequences of providing treatment to people who will
not necessarily become unwell. Specialised treatment services for people with
prodromal symptoms are only justified on an experimental basis.
2. For people in their first episode of psychosis
There is also little evidence to support the intervention of specialist teams for
people in their first episode of psychosis. However, since such people do require
treatment in some form, the ethical issues are less intense than for people
presenting with prodromal symptoms.
The use of first episode teams is therefore ethical even though there is not, as
yet, strong evidence to support it.
PURPOSE OF REVIEW: Over 15 years, early intervention in
psychosis has grown to become a mainstream funded approach to
clinical care. This review examines recent developments in
evaluating the effectiveness of early intervention. It considers
identification and treatment of those at risk of psychosis, as well as
interventions in the post-onset phase of illness. RECENT FINDINGS:
Development of methods identifying those at risk of psychosis
continues to evolve. Promising results in the prevention and delay of
transition to psychotic disorder from a high-risk state have been
found. Psychological and psychosocial interventions are important
components of these preventive programmes. Two recent metaanalyses indicate that there is a consistent relationship between
duration of untreated psychosis and outcome independent of other
factors. Further evidence shows that early intervention reduces the
duration of untreated psychosis, produces better outcomes in terms
of symptomatic and functional domains, and is cheaper than
standard models of care. SUMMARY: There is evidence that early
intervention is effective for early psychosis. Some challenges
remain. These include developing a greater focus on functional
recovery and prevention of relapse.
Killackey and Yung, 2007
Klosterkotter et al., 2008
Physical Health and Mortality
Numerous studies have shown that there is an excess mortality in
people with schizophrenia, the overall mortality being twice as high as
that in the general population.
Suicide and accidents account for only a part of this excess mortality;
a substantial proportion is due to physical illness.
Approximately a quarter of the excess mortality in schizophrenia is
attributable to higher rates of suicide and about 10% to greater risk of
accidents
Suicide is the specific cause contributing to the largest number of
excess deaths among males whereas cardiovascular disease is the
single largest contributor to excess mortality among females with
schizophrenia
Tandon et al., 2008; Leucht et al. 2007; von Hausswolff-Juhlin et al., 2009
Physical Health and Mortality
Cardiovascular events contribute most strongly to the excess
mortality observed in schizophrenia.
Other factors that contribute significantly include obesity, metabolic
aberrations, smoking, alcohol, lack of exercise and poor diet.
The mortality gap between those with schizophrenia and the
general population has progressively increased over the past three
decades
Tandon et al., 2008; Leucht et al. 2007; von Hausswolff-Juhlin et al., 2009
References:
•Hegarty JD, Baldessarini RJ, Tohen M, Waternaux C, Oepen G. One hundred years of schizophrenia: a
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•Killackey E, Yung AR. Effectiveness of early intervention in psychosis. Curr Opin Psychiatry. 2007
Mar;20(2):121-5.
•Klosterkötter J, Schultze-Lutter F, Ruhrmann S. Kraepelin and psychotic prodromal conditions. Eur Arch
Psychiatry Clin Neurosci. 2008 Jun;258 Suppl 2:74-84.
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schizophrenia: recommendations for their use and their presentation. Acta Psychiatr Scand Suppl.
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•Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of
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