Prognosis Prognostic
in
Schizophrenia
Predictors and Outcome
Roger C. Bland, MB, FRCP(C); Jack \s=b\ Eighty-eight of 92 first-admission schizophrenics from 1963, incidence by first admission cohort, were followed up in 1974
an
and 1975. Epidemiologically the sample was more comparable to lower European rates and expectancy rather than to higher American figures. Prior to follow-up, factors said to predict outcome were scored. This prognostic information was complete for 79 cases. Outcome was measured on a variety of criteria. The patients fell into a "poor prognosis" group based on the prognostic indicators, which were of little value in predicting prognosis within this group. However, patients who received extensive service during the follow-up period had poorer outcomes. Outcome was better than in most earlier studies of schizophrenia, but similar to that in some other recent studies of firstadmission patients; also, the use of phenothiazines, short-term hospitalization, and community services may play a part. The failure of prognostic indicators to predict more than about 25% of the outcome variance for this group of "poor prognosis" patients supports the viewpoint that "good" and "poor" prognosis schizophrenia are two different entities.
(Arch Gen Psychiatry 35:72-77, 1978)
prognostic Studi e s generally tionship
indicators in schizophrenia have considered either diagnostic criteria in rela¬ to outcome1·2 or social and history variables1''' in trying to define both outcome and subtypes of schizophre¬ nia. In many of the earlier studies that found a clear relationship between clinical and social prognostic factors and outcome, a relatively small proportion of the patients were actually released from the hospital,7 and Vaillant1 claimed that predictive success was related to the rigor with which recovery was defined. More recent work has shown the importance of defined outcome criteria.7"'" This latter work indicated that on
publication Sept 8, 1977. Department of Psychiatry, University of Alberta, Edmonton (Dr Bland), and Alberta Hospital, Ponoka (Mr Parker and Ms Orn). Reprint requests to Department of PsBland)., University of Alberta, Edmonton, Alberta, Canada T6G 2G3 (Dr"Bland)" Accepted
From the
for
H.
Parker, RPN;
outcome is
on a
Helene Orn
continuum and consists of several different
aspects, eg, clinical, social, occupational, and while these factors show
a degree of commonality, they also exhibit independence from one another. It has also been found that if schizophrenia is diagnosed within a reasonably narrow frame of reference, specific diagnostic criteria are not particularly good overall outcome predictors.11 An infrequently considered methodological problem is the stage of the illness at which cases enter a study, that is, r-
whether an included case is acute or chronic, and whether from first or subsequent admissions. Ideally, studies and predictions should be prospective but even; for example, in the International Pilot Study of Schizophrenia,11 estab¬ lished chronic cases may be included as well as acute cases. Another problem is how representative the selected cases are of schizophrenia as it occurs in the population at large. We believe that these two particular problems do not occur in the present study, as the patient group consists of an incidence by first admission cohort. However, this does mean that the criterion of an established illness, considered by Feighner et al14 to be essential for diagnosis, was sacrificed. Although this is a retrospective study, prog¬ nostic indicator data were determined prior to knowledge of the outcome. This part of the study will examine the nature of the outcome, the nature and relevance of the predictors, and other factors relevant to outcome. METHOD
The study was part of a ten-year follow-up of first admissions for schizophrenia in 1963, with the follow-up being conducted in 1974 and 1975.» All files of first-admission schizophrenics for 1963 to Alberta Hospital, Ponoka were examined. One hundred twenty-five cases were recorded. Cases were excluded if found not to be a first psychiatric hospitalization, if data were inadequate for diagnosis, if alternative psychiatric diagnoses were given, or if a significant secondary diagnosis (such as head injury, organic brain disease, alcoholism or drug abuse, or mental deficiency) was noted on the index or subsequent admissions. All cases fulfilled DSM II criteria
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Otago Library User on 07/04/2015
for schizophrenia, and in the majority of cases had been confirmed by at least two psychiatrists. This procedure led to a final series of 92 cases, of which 88 were successfully followed up, by direct contact with
with the
patients, relatives, physicians, or others concerned patient. Twelve patients (ten men, two women) had died;
information on them is included up to the time of death. The files of 86 cases were checked on the Research Diagnostic Criteria of Spitzer et al.16 Sixty-two cases (72%) were "definite schizophre-
nia," 21 (24%) "probable," and 3 (3%) nonschizophrenic. Two of the nonschizophrenic cases were probably affective, but not fulfilling the criteria for a major depressive illness. Forty-six patients (53%) were recorded as having Schneiderian first-rank symptoms. Many of the earlier studies do not make clear the methods of treatment used in included cases. In our study, all but one of the 88 patients were treated: 65 received antipsychotics, 21 received electroconvulsive therapy (ECT) and antipsychotics, and one ECT alone. Since at this time Alberta Hospital Ponoka served the southern half of the Province of Alberta, cases are considered representa¬ tive of those occurring in a large unselected population (of 662,181). This was confirmed by the fact that calculation of agespecific admission rates and expectancies proved comparable to
Table 1 .—Outcome Measures Score
Psychiatric condition Recovered, no social or intellectual deficit Periodic mild social and/or intellectual deficit Periodic severe social and/or intellectual deficit Mild chronic social and/or intellectual defict Chronic severe social and/or intellectual deficit Chronic unremitting institutionalized Social adjustment Good (normal relationships with named persons, attends regular functions) Fair (few friends or close relationships, may attend functions but not committed and attendance
accepted European figures. After patient selection, data were coded on a variety of demo¬ graphic and historical features from the initial admission records, before any patient was traced for follow-up (in 1974 and 1975). From the files, the patients, and other informants, information on subsequent progress, consumption of care, and outcome was obtained. Follow-up interviews were done by an experienced research interviewer (H.O.), using a semistructured interview. Outcome
was
considered to consist of several components,
including psychiatric condition, social adjustment, and economic productivity. These were rated as shown in Table 1. A score was assigned to outcome on psychiatric condition, social adjustment, and economic productivity to give a combined outcome measure, with a maximum (good outcome) score of 9 and a minimum (poor
Irregular) Poor (no close relationships, avoids social contacts) Disruptive (few relationships and these with periodic quarrels) Recluse (no friends or acquaintances, hermit¬ like existence)
outcome)
score of 0. An additional outcome measure used was whether the patient was alive or dead at the time of follow-up. Each of the 16 historical and demographic factors was then examined against the outcome measures in an attempt to deter¬ mine which of these items might have some significant relation¬ ship to outcome. This historical and demographic information was complete for 79 of the 88 cases (historical data was incomplete or unrateable on the other nine cases), and these 79 patients (43 men, 36 women, of whom eight men and one woman were dead at the time of follow-up) were used in analyses of the interrelationships between predictors and of predictors to outcome. A particular
No data Economic productivity rating Normal (holds a job for a number of years or its duration or changes for adequate reasons) Fair (holds a job for its duration or at least three months, but has periods of unemployment) Minimal (does find work but js voluntarily out of work more often than working) Nonproductive (does not work, or quits as soon as
possible)
Not known
40 00 00
Psychiatrie Condition
II
Social
Adjustment Economie Productivity
30(0
o
'iQ_
20
i
O
^5
10-
lililí-lili
0
3
Severe
None
Impairment Fig 1 .—Outcome
01
23456789
Severe
Fig
measures.
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Otago Library User on 07/04/2015
None 2.—Combined outcome.
problem
the
was
difficulty
with
family history
of
psychiatric
(from files), which cannot be regarded with the degree of reliability as in studies in which all relatives illness
same were
interviewed.
RESULTS Nature of Outcome
Figure 1 shows the scoring of the patients (N 88) on the three outcome rating scales of psychiatric condition, =
social adjustment, and economic productivity. Figure 2 shows the combined outcome, obtained by summing the three components for each patient. It is obvious that for all scales more patients scored at "no impairment" than at any other point. Intercorrelations (Kendall's r) between the three scales were between .54 and .65. Although one third of the patients had a combined outcome score of 9, indicating no impairment in any area, 35% to 58% scored as "no impairment" on the individual scales.
Table 2—Distribution of Prognostic Predictors ( =79) Males
Total
Females
Age.yr 14-19
20-29 30-39
25 26 15
14
40-49
50-59 60+ Total
43
79
36
Education, yr
12 33
13
28 Absent
Present
No. 15 10 41
Acute onset* t
Precipitating factors't Marriedt Good work
historyt
21
19 13 52 65 56 27
11 29
37
30
38
50 53 19
63 67
51
Depressive features* tí No schizoid
personality't
Guiltt Confusion* t Concern with death* No emotional bluntingt
Intelligence average or abovet No schizophrenic family historyt Depressive family history* *
Vaillants5
seven
No. 64 69 38
81 87 48
28 35 58 68 50
35 73 86 63 73
68 49 29
62
37 33
26 60
24
76
factors.
t Stephens and colleagues'3 11 factors. Stephens and colleagues' definition of "presence of depressive features,'
not Vaillants
"symptoms suggesting psychotic depression.'
Table
Age Sex
Single/Married
Education
Acute Onset
Precipitating
Good Premorbid Work History
.40+
.29
.42+
Age Single/married
.27
Education
.54
Acute onset
Precipitating factors Good premorbid work history Depression Not schizoid Guilt Confusion Concern with death No blunting
Intelligence No schizophrenic family history *
The numbers are coefficients of association W> or Cramer's V as appropriate). based on 2 (with continuity correction for 2X2 tables) ·
+ P
in
Schizophrenia
Predictors and Outcome
Roger C. Bland, MB, FRCP(C); Jack \s=b\ Eighty-eight of 92 first-admission schizophrenics from 1963, incidence by first admission cohort, were followed up in 1974
an
and 1975. Epidemiologically the sample was more comparable to lower European rates and expectancy rather than to higher American figures. Prior to follow-up, factors said to predict outcome were scored. This prognostic information was complete for 79 cases. Outcome was measured on a variety of criteria. The patients fell into a "poor prognosis" group based on the prognostic indicators, which were of little value in predicting prognosis within this group. However, patients who received extensive service during the follow-up period had poorer outcomes. Outcome was better than in most earlier studies of schizophrenia, but similar to that in some other recent studies of firstadmission patients; also, the use of phenothiazines, short-term hospitalization, and community services may play a part. The failure of prognostic indicators to predict more than about 25% of the outcome variance for this group of "poor prognosis" patients supports the viewpoint that "good" and "poor" prognosis schizophrenia are two different entities.
(Arch Gen Psychiatry 35:72-77, 1978)
prognostic Studi e s generally tionship
indicators in schizophrenia have considered either diagnostic criteria in rela¬ to outcome1·2 or social and history variables1''' in trying to define both outcome and subtypes of schizophre¬ nia. In many of the earlier studies that found a clear relationship between clinical and social prognostic factors and outcome, a relatively small proportion of the patients were actually released from the hospital,7 and Vaillant1 claimed that predictive success was related to the rigor with which recovery was defined. More recent work has shown the importance of defined outcome criteria.7"'" This latter work indicated that on
publication Sept 8, 1977. Department of Psychiatry, University of Alberta, Edmonton (Dr Bland), and Alberta Hospital, Ponoka (Mr Parker and Ms Orn). Reprint requests to Department of PsBland)., University of Alberta, Edmonton, Alberta, Canada T6G 2G3 (Dr"Bland)" Accepted
From the
for
H.
Parker, RPN;
outcome is
on a
Helene Orn
continuum and consists of several different
aspects, eg, clinical, social, occupational, and while these factors show
a degree of commonality, they also exhibit independence from one another. It has also been found that if schizophrenia is diagnosed within a reasonably narrow frame of reference, specific diagnostic criteria are not particularly good overall outcome predictors.11 An infrequently considered methodological problem is the stage of the illness at which cases enter a study, that is, r-
whether an included case is acute or chronic, and whether from first or subsequent admissions. Ideally, studies and predictions should be prospective but even; for example, in the International Pilot Study of Schizophrenia,11 estab¬ lished chronic cases may be included as well as acute cases. Another problem is how representative the selected cases are of schizophrenia as it occurs in the population at large. We believe that these two particular problems do not occur in the present study, as the patient group consists of an incidence by first admission cohort. However, this does mean that the criterion of an established illness, considered by Feighner et al14 to be essential for diagnosis, was sacrificed. Although this is a retrospective study, prog¬ nostic indicator data were determined prior to knowledge of the outcome. This part of the study will examine the nature of the outcome, the nature and relevance of the predictors, and other factors relevant to outcome. METHOD
The study was part of a ten-year follow-up of first admissions for schizophrenia in 1963, with the follow-up being conducted in 1974 and 1975.» All files of first-admission schizophrenics for 1963 to Alberta Hospital, Ponoka were examined. One hundred twenty-five cases were recorded. Cases were excluded if found not to be a first psychiatric hospitalization, if data were inadequate for diagnosis, if alternative psychiatric diagnoses were given, or if a significant secondary diagnosis (such as head injury, organic brain disease, alcoholism or drug abuse, or mental deficiency) was noted on the index or subsequent admissions. All cases fulfilled DSM II criteria
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Otago Library User on 07/04/2015
for schizophrenia, and in the majority of cases had been confirmed by at least two psychiatrists. This procedure led to a final series of 92 cases, of which 88 were successfully followed up, by direct contact with
with the
patients, relatives, physicians, or others concerned patient. Twelve patients (ten men, two women) had died;
information on them is included up to the time of death. The files of 86 cases were checked on the Research Diagnostic Criteria of Spitzer et al.16 Sixty-two cases (72%) were "definite schizophre-
nia," 21 (24%) "probable," and 3 (3%) nonschizophrenic. Two of the nonschizophrenic cases were probably affective, but not fulfilling the criteria for a major depressive illness. Forty-six patients (53%) were recorded as having Schneiderian first-rank symptoms. Many of the earlier studies do not make clear the methods of treatment used in included cases. In our study, all but one of the 88 patients were treated: 65 received antipsychotics, 21 received electroconvulsive therapy (ECT) and antipsychotics, and one ECT alone. Since at this time Alberta Hospital Ponoka served the southern half of the Province of Alberta, cases are considered representa¬ tive of those occurring in a large unselected population (of 662,181). This was confirmed by the fact that calculation of agespecific admission rates and expectancies proved comparable to
Table 1 .—Outcome Measures Score
Psychiatric condition Recovered, no social or intellectual deficit Periodic mild social and/or intellectual deficit Periodic severe social and/or intellectual deficit Mild chronic social and/or intellectual defict Chronic severe social and/or intellectual deficit Chronic unremitting institutionalized Social adjustment Good (normal relationships with named persons, attends regular functions) Fair (few friends or close relationships, may attend functions but not committed and attendance
accepted European figures. After patient selection, data were coded on a variety of demo¬ graphic and historical features from the initial admission records, before any patient was traced for follow-up (in 1974 and 1975). From the files, the patients, and other informants, information on subsequent progress, consumption of care, and outcome was obtained. Follow-up interviews were done by an experienced research interviewer (H.O.), using a semistructured interview. Outcome
was
considered to consist of several components,
including psychiatric condition, social adjustment, and economic productivity. These were rated as shown in Table 1. A score was assigned to outcome on psychiatric condition, social adjustment, and economic productivity to give a combined outcome measure, with a maximum (good outcome) score of 9 and a minimum (poor
Irregular) Poor (no close relationships, avoids social contacts) Disruptive (few relationships and these with periodic quarrels) Recluse (no friends or acquaintances, hermit¬ like existence)
outcome)
score of 0. An additional outcome measure used was whether the patient was alive or dead at the time of follow-up. Each of the 16 historical and demographic factors was then examined against the outcome measures in an attempt to deter¬ mine which of these items might have some significant relation¬ ship to outcome. This historical and demographic information was complete for 79 of the 88 cases (historical data was incomplete or unrateable on the other nine cases), and these 79 patients (43 men, 36 women, of whom eight men and one woman were dead at the time of follow-up) were used in analyses of the interrelationships between predictors and of predictors to outcome. A particular
No data Economic productivity rating Normal (holds a job for a number of years or its duration or changes for adequate reasons) Fair (holds a job for its duration or at least three months, but has periods of unemployment) Minimal (does find work but js voluntarily out of work more often than working) Nonproductive (does not work, or quits as soon as
possible)
Not known
40 00 00
Psychiatrie Condition
II
Social
Adjustment Economie Productivity
30(0
o
'iQ_
20
i
O
^5
10-
lililí-lili
0
3
Severe
None
Impairment Fig 1 .—Outcome
01
23456789
Severe
Fig
measures.
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Otago Library User on 07/04/2015
None 2.—Combined outcome.
problem
the
was
difficulty
with
family history
of
psychiatric
(from files), which cannot be regarded with the degree of reliability as in studies in which all relatives illness
same were
interviewed.
RESULTS Nature of Outcome
Figure 1 shows the scoring of the patients (N 88) on the three outcome rating scales of psychiatric condition, =
social adjustment, and economic productivity. Figure 2 shows the combined outcome, obtained by summing the three components for each patient. It is obvious that for all scales more patients scored at "no impairment" than at any other point. Intercorrelations (Kendall's r) between the three scales were between .54 and .65. Although one third of the patients had a combined outcome score of 9, indicating no impairment in any area, 35% to 58% scored as "no impairment" on the individual scales.
Table 2—Distribution of Prognostic Predictors ( =79) Males
Total
Females
Age.yr 14-19
20-29 30-39
25 26 15
14
40-49
50-59 60+ Total
43
79
36
Education, yr
12 33
13
28 Absent
Present
No. 15 10 41
Acute onset* t
Precipitating factors't Marriedt Good work
historyt
21
19 13 52 65 56 27
11 29
37
30
38
50 53 19
63 67
51
Depressive features* tí No schizoid
personality't
Guiltt Confusion* t Concern with death* No emotional bluntingt
Intelligence average or abovet No schizophrenic family historyt Depressive family history* *
Vaillants5
seven
No. 64 69 38
81 87 48
28 35 58 68 50
35 73 86 63 73
68 49 29
62
37 33
26 60
24
76
factors.
t Stephens and colleagues'3 11 factors. Stephens and colleagues' definition of "presence of depressive features,'
not Vaillants
"symptoms suggesting psychotic depression.'
Table
Age Sex
Single/Married
Education
Acute Onset
Precipitating
Good Premorbid Work History
.40+
.29
.42+
Age Single/married
.27
Education
.54
Acute onset
Precipitating factors Good premorbid work history Depression Not schizoid Guilt Confusion Concern with death No blunting
Intelligence No schizophrenic family history *
The numbers are coefficients of association W> or Cramer's V as appropriate). based on 2 (with continuity correction for 2X2 tables) ·
+ P
