The natural history of schizophrenia before the neuroleptic era

Since the great majority of schizophrenic patients are today receiving pharmacological treatment, current and recent studies may not reflect the 'natural' course and outcome of the disorder. Two recent studies in Scotland'3) and India(4) estimated the proportions of never-hospitalized schizophrenic patients at 6.7 per cent and 28.7 per cent respectively. About half of the Scottish patients had been prescribed neuroleptics by their general practitioners while the Indian patients had been virtually untreated. However, in both settings the outcomes of these interesting samples (which presumably approximate the 'natural' history of the disorder) were heterogeneous and, by and large, did not differ from the outcomes in the treated groups. In a historical study of 70 Swedish patients with first admissions in 1925, the lifetime records were retrieved and rediagnosed in accordance with DSM-III.(5) None of these patients had received neuroleptics. The final outcome was rated as good in 33 per cent (but no patient was considered as completely recovered), as 'profoundly deteriorated' in 43 per cent, and as intermediate in 24 per cent.

Another, long-term perspective on the course of schizophrenia over successive generations is provided by a meta-analysis of 320 outcome studies on schizophrenia or dementia praecox published between 1895 and 1992 and including a total of 51 800 subjects.(6) Overall, about 40 per cent of the patients were reported as improved after an average length of follow-up 5.6 years. There was a significant increase in the rate of improvement during the period 1956 to 1985 compared with 1895 to 1955, clearly related to the introduction of neuroleptic treatment, (7) but a secular trend towards better outcomes with every successive decade had been present for much longer. Coupled with the virtual disappearance of the most malignant or 'catastrophic' forms of schizophrenia resulting in a profound defect state after a first psychotic episode, or death ('lethal catatonia'), these observations suggest that some transition to a less deteriorating course of the disorder had occurred prior to modern pharmacological treatment.(8) Among the factors explaining this shift one should consider improvements in general care, progressive changes in attitudes and hospital regime which occurred in a number of institutions on both sides of the Atlantic in the 1930 and 1940s, as well as heightened expectations that psychosocial measures such as psychotherapy or rehabilitation could result in a cure in some cases.

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