Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-094Rehabilitation and Long-term ManagementRobert PughSt Luke’s–Woodside Hospital, London, UKTHE LONG-TERM OUTCOME OF SCHIZOPHRENIASchizophrenia has been conventionally considered to be adisorder with a poor long-term prognosis. The concept ofschizophrenia as a disorder with a poor prognosis was reflectedby DSM-III 1 , where features included a failure to return to premorbidfunctioning, recurrent acute exacerbation with increasingresidual impairment between episodes, continued symptoms,unemployment, social isolation and an inability for self-care.DSM-IV 2 included a revised view of schizophrenia, stating thatmost studies of the outcome of schizophrenia suggest that thecourse may be variable, with some individuals displayingexacerbation and remission, whereas others remain chronically ill.The pessimistic views on outcome had mainly been formedfrom the early longitudinal studies reported by Kraepelin 3 andEugen Bleuler 4 . In the course of his work, Kraepelin becamepessimistic about the outcome of dementia praecox, reporting thatfewer than 5% of patients sustained a lasting recovery. WhenEugen Bleuler originally described the concept of schizophrenia,an essential component of the diagnosis was that patients were notable to regain their premorbid abilities. These early studies havehad a major effect on our concept of schizophrenia. Indeed, manypsychiatrists 5,6 considered that if a patient makes a good recovery,then the validity of the diagnosis of schizophrenia may be inquestion. These views still persist and have had a major effect onservice planning for people suffering from schizophrenia and theirmedical management. Five, large, long-term studies of schizophreniapatients have produced very different results from thoseof Kraepelin and Bleuler and have effectively challenged this view.Harding et al. 7,8 carried out a 32 year follow-up study of arehabilitation programme of comprehensive rehabilitation andcommunity placement for those ‘‘backward’’ patients who hadnot improved sufficiently following the introduction of chlorpromazine.A total of 269 patients who were considered to beamongst the most severely disabled and chronically mentally ill inthe hospital were referred to the programme. After an average of32 years, 178 were still alive and were interviewed again; 71patients had died and in these cases the family were interviewed;13 other patients were still alive but refused participation; and theremaining seven could not be located. A battery of interviewinstruments described as the Vermont Community Questionnairewas used to evaluate outcome. Evidence of good inter-raterreliability and face and construct validity for the questionnairesare presented in their paper. The patients were rediagnosed usingDSM-III classification retrospectively: 188 of the original subjectswere considered to have met the DSM-III criteria for schizophrenia.The results showed that the long-term outcome wasmixed, with many patients demonstrating various degrees ofproductivity, social involvements and competent functioning;68% of the patients displayed neither positive nor negativesymptoms of schizophrenia at follow-up and 45% of the sampledisplayed no psychiatric symptoms at all; 82% of patients had notbeen in hospital in the last year; 61% met with friends every weekor two; 68% had one or more moderately/very close friends; 40%had been employed in the past year; 81% were rated as being ableto meet basic needs; and 73% were felt to lead a moderate to veryfull life. The study also includes an assessment of income; 77% ofthe sample were assessed on the Community Care Schedule ashaving an adequate income. The schedule’s definition of ‘‘adequate’’was that ‘‘the amount of money received will cover thesubject’s basic needs comfortably’’. Four other studies reportsimilar findings.Manfred Bleuler 9 described a follow-up study of 208 patientswho met his own and Eugen Bleuler’s diagnostic criteria forschizophrenia, and reported a significant improvement in 53% ata 23 year follow-up.Huber et al. 10 described the largest study, following up 502patients over an average of 22.4 years, using the diagnostic criteriaof E. and M. Bleuler 4,9,11 and Schneider 12 ; 53% showed significantor total improvement.Ciompi and Muller 13 followed up 289 patients admitted beforethe age of 65 who were over 65 by 1963. The mean length offollow-up was 36.9 years. The diagnostic criteria of E. and M.Bleuler were used; again, over 50% (57%) of patients showedsignificant improvement.Tsuang et al. 14 followed 186 patients admitted to Iowa StateHospital between 1934 and 1944 for a period of 35 years. In thisstudy, 46% showed significant improvement.The results of these studies challenge the prevailing concept ofoutcome in schizophrenia and support the concept of heterogeneityof outcome. Together, these studies found that betweenone-half and two-thirds of more than 1300 patients studied for aperiod in excess of 20 years achieved recovery or significantimprovement. This is not to deny the fact that many patients donot show an improvement over the years and require continuingmedical and social support, but it clearly suggests that it iserroneous to view deterioration as an inevitable outcome.The differences between these studies and those of Kraepelinand Bleuler have been attributed to sampling biases. The criticismhas been that both Kraepelin and Bleuler chose samples ofpatients who were admitted to hospital for long-term care. Inaddition to this, Kraepelin’s studies probably included patientswith tertiary syphilis and other organic disorders for which testswere unavailable at the time. Certainly, Eugen Bleuler’s son,Manfred Bleuler, attributed his father’s pessimism about theoutcome of schizophrenia to this bias.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd