Comment
Comment by:  Amresh Shrivastava
Submitted 16 July 2009
Posted 16 July 2009
 

Perspectives in social outcome of schizophrenia
The ongoing discussion about social outcome is exciting and timely. Repeatedly it has been demonstrated that only clinical remission does not reflect “real-life” situation (Eberhard et al., 2009; Cassidy et al., 2009). The decline in social functions not only forms a pathognomonic symptom of schizophrenia but also serves as a marker and predictor for outcome status. Further, social outcome in early psychosis also serves as an indicator, which helps differentiate various syndromes amongst the broad classification of “non-affective psychosis” or “schizophrenia spectrum disorder” (Horan et al., 2009). The early intervention research for at-risk individuals is faced with three main difficult objectives:

1. To identify whether the individual will transition to florid psychotic state, no matter of what diagnostic category.

2. To find measures which can contain the [...continued] transition and restore the psychosocial functions.

3. To develop clinical markers which can predict with high reliability and specificity chances of developing hardcore schizophrenia.

The appropriateness of multidimensional measurement of outcome needs to be investigated. We suggest that it needs to measure at least on two different parameters: clinical and social.

Research in the early phase of psychosis has developed evidence for early intervention, particularly “critical period” (Birchwood et al., 1998; Cassidy et al., 2009). It provides scientific and biological arguments for early identification and treatment. Furthermore, it has been suggested that the critical period should be extended to include prodromal as well as early phase of psychosis. There is more to “early intervention” in psychosis than merely intervening early.

The long-term outcome of schizophrenia should answer these two questions:

1. What do we do to maximize outcome and achieve complete social integration, and when?

2. How can we identify subjects who may not respond favorably to treatments and facilitate planning for impending disability right from the beginning?

Social outcome
In the literature, social recovery (overall good outcome) is measured by different social and occupational parameters and is found to be around 40-60 percent (Priebe, 2007). One of our long-term follow-up studies (Srivastava, A, Thakar, M, unpublished) attempted to identify the effects of multiple outcome criteria in 10 years’ long-term follow-up of first-episode hospitalized patients. The social parameters included quality of life, level of functioning, independent living, interpersonal social functioning, work and employment, presence of family burden, and social burden (Meltzer et al., 1997). We observed that outcome status declines if both clinical and social parameters are included: 61 percent of patients showed clinical remission, 32 percent showed good social remission, and only 25 percent improved on both clinical and social parameters. Just 10 percent of the patients fulfilled a maximum of four parameters. The largest group of patients (25.7 percent) recovered on only two parameters. Social parameters appear to be inter-dependent, yet recovery on any one parameter is not associated with recovery on any other parameter. Therefore, some patients are employed but unable to live independently and others show good quality of life but are still unable to be gainfully employed. In this study it is observed that only 23-25 percent of patients show social recovery on two to three different parameters.

Conceptual framework
The outcome criteria have been ill defined for long-term studies. Commonly used outcome terminology has been “poor outcome," "good outcome," "favorable outcome," "unfavorable outcome," "hospitalization," "repeated relapse rate," "living with family," "return to education," "employment," and "marital status." It is difficult to arrive at a conclusion for minimum criteria for defining “good outcome” in the long term. Recently there have been a few attempts to look at this aspect scientifically (Addington et al., 2004; Crumlish et al., 2009), particularly from the working group of the American Psychiatric Association on defining criteria for remission, which has developed a consensus statement about “remission” in schizophrenia. (Andreasen and Olsen, 1982) Based on an examination of popular rating scales (SAPS and SANS, PANSS, and BPRS), the working group identified appropriate criteria to serve as the basis for defining “symptomatic remission” in schizophrenia. In addition, the working group proposed that remission criteria might be described separately for positive and negative symptoms, to allow primary consideration of these symptom groups independently in the assessment of symptomatic remission. Specific items selected for consideration as criteria for remission in schizophrenia were chosen to map the three dimensions of psychopathology identified by factor analyses: 1) psychoticism; 2) disorganization; and 3) negative symptoms. This represents the conceptualization and quantification of remission. It is noteworthy that remission as an outcome measure is far less than what is required to capture real-life outcome. There are expectations from the families and the public at large to define the outcome in a real-life situation.

We therefore propose that outcome needs to be measured on a minimum of two groups of parameters, each having three or more parameters in the least: 1) clinical outcome that measures psychopathology, side effects, and hospitalization. The psychopathology includes aggression, suicidality, and depression besides parameters of “psychoticism”; 2) social outcome, which measures quality of life, global assessment of functioning, and social cognition. The parameter of social cognition includes ability to learn and reproduce, coping, independent living, and interpersonal skills.

We need to investigate dimensions of social decline and social improvements that are objective, definable, and quantifiable. Thus, the ongoing work of social outcome is very significant.

References:

Addington J, Van Mastrigt S, Addington D. Duration of untreated psychosis: impact on 2-year outcome. Psychol Med. 2004 Feb 1;34(2):277-84. Abstract

Andreasen NC, Olsen S. Negative v positive schizophrenia. Definition and validation. Arch Gen Psychiatry. 1982 Jul 1;39(7):789-94. Abstract

Birchwood M, Todd P, Jackson C. Early intervention in psychosis. The critical period hypothesis. Br J Psychiatry Suppl. 1998 Jan 1;172(33):53-9. Abstract

Cassidy CM, Norman R, Manchanda R, Schmitz N, Malla A. Testing Definitions of Symptom Remission in First-Episode Psychosis for Prediction of Functional Outcome at 2 Years. Schizophr Bull. 2009 Mar 25; Abstract

Crumlish N, Whitty P, Clarke M, Browne S, Kamali M, Gervin M, McTigue O, Kinsella A, Waddington JL, Larkin C, O”Callaghan E. Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis. Br J Psychiatry. 2009 Jan 1;194(1):18-24. Abstract

Eberhard J, Levander S, Lindström E. Remission in schizophrenia: analysis in a naturalistic setting. Compr Psychiatry. 2009 May-Jun ;50(3):200-8. Abstract

Horan WP, Kern RS, Shokat-Fadai K, Sergi MJ, Wynn JK, Green MF. Social cognitive skills training in schizophrenia: an initial efficacy study of stabilized outpatients. Schizophr Res. 2009 Jan 1;107(1):47-54. Abstract

Meltzer HY, Rabinowitz J, Lee MA, Cola PA, Ranjan R, Findling RL, Thompson PA. Age at onset and gender of schizophrenic patients in relation to neuroleptic resistance. Am J Psychiatry. 1997 Apr 1;154(4):475-82. Abstract

Priebe S. Social outcomes in schizophrenia. Br J Psychiatry Suppl. 2007 Aug 1;50():s15-20. Abstract

Srivastava, Amresh and Thakar, Meghan, Outcome in Schizophrenia: The Long-Term Good Outcome in Schizophrenia Is Not Yet Good Enough (2008). Psychiatry Presentations. Paper 7.