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| Longitudinal studies of outcome |
Longitudinal studies of outcome
The Vermont longitudinal study was a landmark study of long-term outcomes of schizophrenia (Harding et al.,1987a, 1987b). This research involved 269 of the most disabled, long-stay patients who had been ill for an average of 16 years, had been totally disabled for 10 years and hospitalized continuously for six years. During the era of deinstitutionalization in the mid-1950s, these patients, who had not responded well to modern drug therapy, took part in a comprehensive rehabilitation programme. Ten years after their release from hospital, 70% remained out of hospital. The study used blind raters and comprehensive, reliable, structured protocols, including the Global Assessment Scale (Endicott, Spitzer and Fliess, 1976), the Strauss–Carpenter Levels of Functioning Scale (Hawk, Carpenter and Strauss, 1975) and 13 other well-established measures. It was found at follow-up 20 to 25 years later, that 68% were functioning at a level most people would consider ‘normal’ (Harding et al., 1987a). When restricting the cohort to those who retrospectively met the DSM-III criteria for schizophrenia, 34% were found to have achieved full recovery, and a further 34% to have achieved significant improvement in both psychiatric status and social functioning. The criteria were strict and included: living in the community, being employed, not using psychiatric medications, being free of symptoms, not having behaviours that would be considered those of a ‘mental patient’, and having good relationships with others (Harding et al., 1987b). Harding and colleagues have championed the cause of heterogeneous outcome expectations for schizophrenia. In a review of longitudinal studies, Harding, Zubin and Strauss (1987) noted a number of methodological problems with earlier studies that had produced contradictory results. They therefore proceeded to review the more recent, methodologically sound studies of the time and found that poor outcomes were much less common than had been previously assumed.
The Harding, Zubin and Strauss, (1987) review included the Vermont study and four other long-term studies: M. Bleuler (1972/1978), Tsuang, Woolson and Fleming (1979), Huber et al. (1980) and Ciompi and Muller (1976). Combining the results of the five studies, Harding, Zubin and Strauss (1987) found that, of over 1300 ex-patients, one-half to two-thirds had recovered or significantly improved. A number of more recent studies have lent further support to these findings. For example, in a five-year follow up study of a cohort of 70 schizophrenia patients, good social functioning was recorded in 62% of the entire cohort, and a good outcome in terms of combined symptoms and hospital admissions for 58% of the first-admission cohort (Shepherd et al., 1989). Harrison et al. (1993) explored 15- and 25-year follow-up outcomes of 644 subjects from theWHOInternational Study of Schizophrenia (ISoS; Sartorius et al., 1996). Using Bleuler’s (1972/1978) scale, 48% of the 15-year incidence cohort and 54% of the 25-year prevalence cohort were rated as recovered, meaning ‘he could be fully employed in meaningful work and resume his former role in society’ (Bleuler, 1972/1978, p. 191). Furthermore, 42% of the total cohort had not experienced a psychotic episode in the past two years.
Mason et al. (1995) conducted a 13-year follow-up study on an incidence cohort of 67 patients. Using measures including positive and negative symptoms, social disability, functioning and treatment status, they found that 44% achieved a ‘mild’ or ‘recovered-treated’ outcome. Using a definition of ‘complete recovery’ as no symptoms, no disability and no treatment, 17% of the sample were completely recovered at follow-up, while using Bleuler’s criteria, approximately 57% were recovered. Harrow et al. (2005) conducted a prospective 15-year follow-up study.
Recovery was defined as status over the follow-up year based on the following criteria: absence of psychotic or negative symptoms, adequate psychosocial functioning including at least half-time employment (not necessarily paid), absence of poor social activity level, and no psychiatric hospitalizations. Harrow et al. found that at 15 years, 19% of the schizophrenia cohort were in recovery. In addition, they found that, over the course of 15 years, 41% of patients had been in recovery at some point, demonstrating that schizophrenia was not necessarily chronic and continuous, but episodic in nature. It is worth noting that the criteria for recovery in some of these studies perhaps describe a higher level of functioning than would be met by many people who do not have a mental illness or other disability.
The Vermont longitudinal study was a landmark study of long-term outcomes of schizophrenia (Harding et al.,1987a, 1987b). This research involved 269 of the most disabled, long-stay patients who had been ill for an average of 16 years, had been totally disabled for 10 years and hospitalized continuously for six years. During the era of deinstitutionalization in the mid-1950s, these patients, who had not responded well to modern drug therapy, took part in a comprehensive rehabilitation programme. Ten years after their release from hospital, 70% remained out of hospital. The study used blind raters and comprehensive, reliable, structured protocols, including the Global Assessment Scale (Endicott, Spitzer and Fliess, 1976), the Strauss–Carpenter Levels of Functioning Scale (Hawk, Carpenter and Strauss, 1975) and 13 other well-established measures. It was found at follow-up 20 to 25 years later, that 68% were functioning at a level most people would consider ‘normal’ (Harding et al., 1987a). When restricting the cohort to those who retrospectively met the DSM-III criteria for schizophrenia, 34% were found to have achieved full recovery, and a further 34% to have achieved significant improvement in both psychiatric status and social functioning. The criteria were strict and included: living in the community, being employed, not using psychiatric medications, being free of symptoms, not having behaviours that would be considered those of a ‘mental patient’, and having good relationships with others (Harding et al., 1987b). Harding and colleagues have championed the cause of heterogeneous outcome expectations for schizophrenia. In a review of longitudinal studies, Harding, Zubin and Strauss (1987) noted a number of methodological problems with earlier studies that had produced contradictory results. They therefore proceeded to review the more recent, methodologically sound studies of the time and found that poor outcomes were much less common than had been previously assumed.
The Harding, Zubin and Strauss, (1987) review included the Vermont study and four other long-term studies: M. Bleuler (1972/1978), Tsuang, Woolson and Fleming (1979), Huber et al. (1980) and Ciompi and Muller (1976). Combining the results of the five studies, Harding, Zubin and Strauss (1987) found that, of over 1300 ex-patients, one-half to two-thirds had recovered or significantly improved. A number of more recent studies have lent further support to these findings. For example, in a five-year follow up study of a cohort of 70 schizophrenia patients, good social functioning was recorded in 62% of the entire cohort, and a good outcome in terms of combined symptoms and hospital admissions for 58% of the first-admission cohort (Shepherd et al., 1989). Harrison et al. (1993) explored 15- and 25-year follow-up outcomes of 644 subjects from theWHOInternational Study of Schizophrenia (ISoS; Sartorius et al., 1996). Using Bleuler’s (1972/1978) scale, 48% of the 15-year incidence cohort and 54% of the 25-year prevalence cohort were rated as recovered, meaning ‘he could be fully employed in meaningful work and resume his former role in society’ (Bleuler, 1972/1978, p. 191). Furthermore, 42% of the total cohort had not experienced a psychotic episode in the past two years.
Mason et al. (1995) conducted a 13-year follow-up study on an incidence cohort of 67 patients. Using measures including positive and negative symptoms, social disability, functioning and treatment status, they found that 44% achieved a ‘mild’ or ‘recovered-treated’ outcome. Using a definition of ‘complete recovery’ as no symptoms, no disability and no treatment, 17% of the sample were completely recovered at follow-up, while using Bleuler’s criteria, approximately 57% were recovered. Harrow et al. (2005) conducted a prospective 15-year follow-up study.
Recovery was defined as status over the follow-up year based on the following criteria: absence of psychotic or negative symptoms, adequate psychosocial functioning including at least half-time employment (not necessarily paid), absence of poor social activity level, and no psychiatric hospitalizations. Harrow et al. found that at 15 years, 19% of the schizophrenia cohort were in recovery. In addition, they found that, over the course of 15 years, 41% of patients had been in recovery at some point, demonstrating that schizophrenia was not necessarily chronic and continuous, but episodic in nature. It is worth noting that the criteria for recovery in some of these studies perhaps describe a higher level of functioning than would be met by many people who do not have a mental illness or other disability.
