Longterm prognosis

Results of course and outcome studies published over the last six decades are shown in Table 1 The studies have been selected on the basis of the length of follow-up (>5 years), effective sample size (>50), and intensity of follow-up and assessment.

Table 1 Results of selected course and outcome studies in schizophrenia, 1939-1998

Three European(l2,14,28> and two North American studies,(l5l6) in which a total of nearly 1300 patients were followed up for 23 to 37 years, provide a global overview of the long-term course of schizophrenia. Although the studies differ in their design (prospective; (1. 1 ,.1..6) follow-back or retrospective(1528), and include patients with onsets in the preneuroleptic era who were later treated with antipsychotic drugs for varying length of time, their results have much in common.

Manfred Bleuler's monograph(l2) is the account of an intensive study of 208 patients first admitted in 1942 to 1943 and personally followed up by the author for 22 years or until death. Another 23-year follow-up of 504 patients admitted in 1945 to 1959 has been completed by Huber et al.'(14> Ciompi(28> interviewed 289 surviving patients in Switzerland first admitted between 1900 and 1962 (median follow-up length 36.9 years).

Notwithstanding methodological constraints that apply to these studies, their findings are a unique record of what probably represents the closest approximation to the 'natural history' of schizophrenia. In summary, they indicate the following.

• Lasting recovery ('complete cure') occurred in 20 to 26 per cent of the cases—according to Ciompi(28) 43 per cent had either remitted or exhibited mild residual abnormalities which did not interfere with their living in the community.

• Forty-four per cent were still in hospital (28> and severe chronic states had developed in 14 to 24 per cent.

• In 50 to 75 per cent of the patients, a clinically stable state set in after the fifth year since onset, with no significant further deterioration.

• Remitting course with multiple episodes and full remissions characterized 22 per cent of the patients; (14) catastrophic course (rapid onset of chronic deterioration) was observed in 1 to 4 per cent.

• The 20-year suicide rate was 14 to 22 per cent.

The two American studies largely concur with these findings. In the Vermont study (1.6> no less than 62 per cent of the cohort had achieved significant improvement or recovery after an average length of follow-up 32 years; the corresponding proportion in the Iowa 500 study (15) was 46 per cent.

The most striking finding from the long-term follow-up studies is the high proportion of patients who recover, either completely or with mild residual abnormalities, after decades of severe illness. This contrasts with the ingrained image of schizophrenia as an intractable, deteriorating illness that many clinicians tend to adopt on the basis of a limited follow-up horizon and patient samples selected for unfavourable course and treatment response. It is unlikely that the high percentage of recoveries in the long-term studies could be explained by cases of affective illness or brief transient psychoses misdiagnosed as schizophrenia (the retrospective rediagnosis of cases according to Feighner's(29> or DSM-III criteria in the two American studies did not alter significantly the results). Similarly unlikely would be the attribution of all the good outcomes to the antipsychotic treatment many of these patients received in the later stages of their illnesses, since comparable proportions of improvement of recovery had been reported for patients who never received neuroleptics.(5) A tentative conclusion from such follow-up research would be that schizophrenia is not invariably a chronic deteriorating disorder and that the progression of the disease can be arrested, or even reversed, at any stage. The causes of such reversibility remain largely unknown, but research focusing specifically on the recovering cases will undoubtedly provide essential clues for understanding the nature of schizophrenia.

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