Limitations of clinical prediction

The explanatory power of any predictor in schizophrenia (in terms of accounting for a proportion of the outcome variance) is likely to vary depending on sample size, setting, homogeneity of patient groups, and measurement error, but generally tends to be limited (rarely exceeding 30 per cent of the outcome variance). This suggests that no single background or premorbid characteristics of the person, and no clinical symptom or sign among the initial manifestations of the disorder, is in a particularly strong association with its prognosis in the longer term. Similarly to the genetic epidemiology of schizophrenia, where non-shared environmental influences account for a greater amount of variance than the shared environment, person-specific emergent life events or changes in the mental state may have a similar or greater impact on outcome than the initial or premorbid predictors. Indeed, variables such as negative symptoms have been shown to gain in predictive power if they are assessed 2 or more years after the onset, or after the patients have received adequate treatment. The predictive capacity of other variables, for example mode of onset(34) or a high index of expressed emotion,(®6) tends to become attenuated in the course of time. Thus, there is no fixed set of predictors of the course and outcome of schizophrenia, but rather a number of prognostic indicators which allow a judgement to be made about the probability of one or another type of course over a limited time period (usually not exceeding 5 years).

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