CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 11COURSE AND OUTCOMEHEINZ HÄFNERWOLFRAM AN DER HEIDENSchizophrenia is a disorder that can be treated successfully. Ethical considerations preventus from studying the untreated illness course. For this reason, our chapter focuses onthe treated course as it presents itself under current conditions of care. This limitationdoes not apply to the untreated early course that precedes first contact.TIME TRENDSSince the beginning of the 20th century, lengths of stay of patients hospitalized for thefirst time with a diagnosis of schizophrenia have shortened dramatically. The reason liesin the change in strategy from long-term custodial care to a primarily open, therapeuticallyactive system of community-based care. This fundamental change, however, doesnot permit us to infer that the natural course of the illness has also changed.Comparisons of the illness course over long periods of time require homogenizationof the study designs (diagnosis, representative study samples, appropriate assessments,etc.). In the largest meta-analysis so far, which covered 320 studies from a period of almost100 years, the increase in global recovery rates that occurred with the advent of traditionalantipsychotics (1895–1955: 35%; 1956–1985: 49%) disappeared unexpectedlyin the subsequent period (1986–1992: 36%) of the new generation of antipsychotic medications(Hegarty, Baldessarini, Tohen, Waternaux, & Oepen, 1994). But a combinationof factors underlies these figures. At any rate, it should be noted that the medications currentlyavailable reduce the intensity and frequency of psychotic episodes but have littleimpact on negative symptoms, and cognitive and functional impairment, which play thegreatest role in global outcome. The only treatment-related improvement that has occurredis an enormous decrease in hospital stays and catastrophic outcomes such as lifethreateningcatatonia in countries with fully developed mental health care systems.100