Facts and Figures

Schizophrenia : Youth’s Greatest Disabler

Course and outcome of schizophrenia

The term ‘course’ refers to the pattern of progression of an illness over a period of time. The common types of courses are continuous illness, a relapsing course with increasing disability, and a single episode followed by complete improvement. Both short and long-term courses have been identified in relation to schizophrenia.

Violence

Studies indicate that people with schizophrenia are not excessively prone to violence, except patients with a past criminal record, history of associated substance abuse or alcohol dependence. More often, patients are withdrawn and prefer to be left alone. However, some patients, particularly during periods when they are hearing voices or imagining threatening gestures targeted towards them, may become violent. Friends and family are usually the target of this violence. Media often links mental illness and violence. However, it has been observed that many schizophrenics are not especially prone to violence. Media often uses terms such as ‘mentally ill’, ‘psychotic’, ‘lunatic’, ‘pagal’, ‘psychopathic’, while sensationalizing crime. This has resulted in the broad myth and perception that all persons with schizophrenia are dangerous.

Outcome

The outcome is the status of the individual at a point in time or at the end point. Depending on the length of time for which the patient is followed up, the outcome can vary from one point in time to another. For chronic illnesses such as schizophrenia, it is more relevant to study the outcome at the end of five or ten years.

In the earlier half of the twentieth century, it was believed that schizophrenia is a prolonged illness with poor long-term prognosis. However, with the introduction of modern medicines, better community care and increasing awareness about the illness, the outcome of schizophrenia has, indeed, changed for the better. This has been adequately borne out by several multicentric studies.

Schizophrenia: patients falling into selected categories of course and outcome variables

Source: Jablensky A., Satorius N, Emberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine. Monograph Supplement 1992;20:1-97. (Reproduced with permission from CambridgeUniversity Press)

Components of outcome

The outcome itself is usually not a unitary one, but has different dimensions. These are as follows.

     Clinical outcome - improvement/persistence/deterioration of symptoms and signs of the disorder, number of relapses, intellectual performance;

     Social functioning of the patient;

     Work performance - this includes work in paid jobs outside the home, housework, studying (if a student), and work in a sheltered environment;

     Quality of life - this is increasingly being recognized as an outcome dimension. 

In one individual, there could be much heterogeneity and only a weak relationship between these outcome dimensions. Though patients may be clinically asymptomatic, their social functioning could be poor and they may be unable to hold a job. It is equally likely that persons suffering from hallucinations or delusions may still be able to keep their job. Hence, for the purpose of psychosocial intervention, it is essential to assess each of these dimensions and plan programmes accordingly.

Family attitudes, emotions, their expression, and the nature and style of communication, have all been associated with an increased rate of relapse in schizophrenia.

Although schizophrenic symptoms are exacerbated following childbirth, the exact relationship is uncertain.

Differences in outcome in developed and developing countries

A remarkable and consistent finding has been that in developing countries, schizophrenics have a better outcome. This was based on the fact that more patients in the developing world remained symptom-free for longer periods after the initial episode. This length of remission (symptom-free period) was unrelated to drug treatment since many in the developing world did not receive continuous treatment. Psychosocial factors, such as better family support, community tolerance, extended networks and more favourable job opportunities, have been postulated as the reasons for this observation. From several studies, it is known that short duration of initial episode, few episodes in the past, good adjustment patterns, being married, early diagnosis and initiation of treatment, acute onset, good social support networks and total compliance to medication are some factors favouring good prognosis in schizophrenia.

Prognostic factors

Of all the prognostic factors outlined above, one single factor amenable to correction and/or modification is proper treatment consisting of early identification, treatment with medicines, family education and psychosocial rehabilitation. Unfortunately, however, health care facilities for such treatment are woefully inadequate in developing countries.

Factors indicating a better outcome in patients:

     Female gender

     Married status

     Early treatment

     Acute onset of illness

     Rural background and cohesive family

     Absence of negative symptoms

     Predominance of florid positive symptoms

     Short duration of first episode

     Few episodes of similar illness in the past

     Good premorbid personality and adjustment

Factors indicating a poor outcome in patients:

     Male gender

     Unmarried status

     Earlier age of onset of illness

     Delayed treatment

     Irregular treatment

     Gradual (insidious) onset of illness

     Lack of social support

     More negative symptoms

     Positive family history of schizophrenia or major psychoses

     Poor social and occupational functioning before the onset of the illness

     Large size of ventricles of the brain, presence of subtle neurological signs

     History of substance abuse or alcohol dependence

     Excessive criticism, hostility or over-involvement in the home and family atmosphere