Thursday, January 28, 2010

Does Schizophrenia Need to Be Treated?

The short answer is "Yes."

However, the dogma about the illness is one of chronicity, that is, schizophrenia is an illness of unremitting symptoms even with the best of treatments.

Is this depiction accurate?

Not entirely, according to Harrow et. al, who set out to answer this question (and many more) in the Schizophrenia Bulletin article "Do Patients with Schizophrenia Ever Show Periods of Recovery? A 15-year Multifollow-Up Study."

The authors wanted to answer 4 questions:
1. Do some or even a large percentage of patients with schizophrenia show periods of recovery? If so, what percentage?
2. Do patients with schizophreniform disorders show more favorable courses and outcomes than patients with schizophrenia? (Yes)
3. Is schizophrenia associated with slower recovery than other psychotic disorders? (Yes)
4. Is psychosis in nonschizophrenia patients a risk factor for subsequent poor outcome? (Maybe)
Since the focus of this post is on the answer to that first question, I've provided the answers to the other questions for brevity (the article is available for free).

Methodology and Study Outcomes:
The study consisted of 274 DSM-III diagnosed patients (64 of whom had schizophrenia) who were studied at 5 different intervals over 15 years. The total diagnostic breakdown and numbers of patients within each diagnosis assessed during each follow-up period are listed below:

Patients were assessed at 2 years, 4.5 years, 7.5 years, 10 years, and 15 years post-initial hospitalization. 

Other schizophrenia patient demographics are listed below:
Recovery was defined rather strictly:
1. the absence of major symptoms throughout the follow-up year (i.e., absence of psychotic activity and absence of negative symptoms).
2. adequate psychosocial functioning, including instrumental (or paid) work half-time or more during the follow-up year.
3. the absence of a very poor social activity level.
4. no psychiatric rehospitalizations during the follow-up year.
The data provided include, "(a) percentage of patients with schizophrenia in recovery at any follow-up year and (b) the cumulative percentage of schizophrenia patients who, over 15 years, ever show the potential for an interval or period of recovery." In other words,the number of patients with schizophrenia who had at least one interval of recovery during the 15 year period.

Here are the percentages of patients that were in recovery during each follow-up interval for each diagnostic group:
On average, during any given follow-up period, approximately 19-22% of schizophrenia patients (out of 64 total) were in remission. All patients groups had their lowest period of recovery during the first two years after hospitalization. The schizophrenia group had the lowest frequency of patient recovery during all follow-up periods.

Here are the cumulative percentages of the patients that had at least one interval of recovery during the entire study period:
As time progressed, the number of patients who experienced at least 1 interval of recovery in each diagnostic group increased. Again, the schizophrenia group had the lowest cumulative number of patients who achieve recovery; 3 out of every 5 schizophrenia patients did not achieve remission.

Here is where it gets interesting:
The majority of the schizophrenia patients, who had at least one interval of recovery, were not being treated with any medications. In the authors' words, "very poor outcome patients with schizophrenia are more likely to be on antipsychotic medications."

One can generate many different hypotheses based on this result. For example, you could argue that psychotropic medications in general, and antipsychotic medications specifically, are dangerous drugs that cause more harm than good.

That's just how two individuals chose to spin this result:
Indeed, these findings indicate that not receiving treatment works better than pharmaceutical intervention. Similarly, University of Illinois researchers recently found that only 5 percent of medicated schizophrenia patients recover, but 40 percent of non-medicated patients recover (Harrow, Grossman, Jobe, and Herbener 2005; also see Harrow and Jobe 2007). In other words, schizophrenia patients are eight times more likely to recover if they are not on medications!(1)
Quick! Somebody notify the APA! We need to start revising all those treatment algorithms, STAT!.

Unfortunately, the authors of that piece, which appeared in the September/October 2008 edition of Skeptical Inquirer, are full of shit (excuse my French, but to call them liars would be considered libel).

Harrow and Thomas, with the same patient cohort, did another study: Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medications - A 15-Year Multifollow-Up Study.

One goal of this study was to examine the "clues on whether the better functioning of the subgroup of unmedicated patients with schizophrenia versus those on antipsychotics at the 15-year follow-up was a function of their current medication status" or "other long-term characteristics marked them off as different types of patients."

They answered this question by comparing the two groups on various premorbid and prognostic factors that were assessed near the beginning of the study.

 In the figure above, we see that unmedicated patients scored better on indices of "favorable prognosis." In the figure below, we also see that unmedicated patients had better scores on "premorbid achievement" measures as well. Keep in mind that these two factors (i.e., favorable prognosis and premorbid achievement) were assessed near the beginning of the study, and not afterward. This means that being on antipsychotics was not a major factor in patient outcomes, suggesting that the better overall recovery of the unmedicated patients was mainly due to long-term patient characteristics.
In the discussion section, the authors summarize their main findings:
"Looking at from a different viewpoint, the data suggests that schizophrenia patients with good prognostic features, with better premorbid developmental achievements and with more favorable personality characteristics are the subgroup more likely to stay off antipsychotics for a prolonged period."
What was identified is a small subset of patients who are able to experience episodes of recovery in the absence of antipsychotics. According to the authors, those patients "who go off antipsychotics are a different type of patient."

There are many things to keep in mind regarding these two research papers. First, the sample is rather small (64 cases of schizophrenia). Of those diagnosed, the majority never did achieved remission. At the end of the study, only 12/64 (19%) patients had been in remission the previous study year. Of those who did achieve remission, many eventually relapsed. And, overall, the schizophrenia patients had significantly poorer outcomes when compared to all other clinical groups...Oh screw it, who wants pie?

Harrow M, Grossman LS, Jobe TH, & Herbener ES (2005). Do patients with schizophrenia ever show periods of recovery? A 15-year multi-follow-up study. Schizophrenia bulletin, 31 (3), 723-34 PMID: 16020553

Harrow M, & Jobe TH (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. The Journal of nervous and mental disease, 195 (5), 406-14 PMID: 17502806


Anonymous said...

What do you mean by "your training"? What is your educational backgroud? Are you in practice? What is your scope of practice? Do you have a license to practice?

Anonymous said...

How do you come to an answer of "yes" based on this paper? I cannot see how you come to any possible conclusion on this data one way or another except maybe those who present as worse off get meds. I certainly do not see how you pull out that they are better or even worse off and therefore they should get TX? Please explain. Thanks

Neuroskeptic said...

An interesting paper I came across recently -
Deinstitutionalization revisited

They took 1st episode schizophrenia(ish) patients, who were about to be discharged from hospital, and randomized them to stay in hospital (voluntarily!) for a few extra months (sounds like it was an especially nice ward too), get extra out of hospital psychosocial care, or treatment as usual.

The group who got the extra inpatient stay were more likely to be readmitted to hospital or to live in supported housing. For at least 5 years. They suggested that hospitalization time leads to loss of skills for living outside...

NeuroPsych said...

Anonymous2: I'm not entirely clear on what you are asking. I assume that you are referring to research question 1, "Do some or even a large percentage of patients with schizophrenia show periods of recovery? If so, what percentage?"

Is that correct?

Recovery was defined as the absence of major symptoms throughout the follow-up year, adequate psychosocial functioning, including instrumental (or paid) work half-time or more during the follow-up year, the absence of a very poor social activity level, and no psychiatric rehospitalizations during the follow-up year.

The way the study worked was like this: patients were initially hospitalized for acute psychosis and other psychosocial impairments. They were treated with psych meds, etc.

Once they were discharged, they received "care as usual," which is defined as the standard in that community (Chicago in this case).The patients were assess 5 times over 15 years for the study in addition to the routine care they were already receiving.

The answer to the above question is "yes" because some patients (approx 40%) did meet the operational definition of recovery during the 15 year period.

Anonymous1: I own all 5 seasons of House and the first 3 seasons of Quincy. I practice in my uncle’s basement in between my other duties as a wet nurse and dog whisperer. In other words, I did the whole grad school/dissertation thing, followed by the whole internship/fellowship thing, and currently do the in/out patient rehabilitation thing at a hospital.

Anonymous said...

There was an interview with Nancy Andreasen, M.D. in the NY Times about two years ago. In that interview,she said she had compelling data that antipsychotic medication, though necessary to treat acute symptoms of schizophrenia, had terrible long term effects due to destruction of basal ganglia associated with medication use. The Harrow study is in line with Andreasen's observations.

Dr John said...

I am sorry I was not clear on my question. My question was that in your very first sentence you ask "should Schizophrenia be treated?" and you answer "yes". You then go on to explain the outcomes of this study very well but I do not see at all how this study answers if "schizophrenia" should be treated.Sure some recovered based on what appear to be pre-morbid factors. How do you attribute recovery to "Tx" based on this study as I assume you are when you come to the conclusion that this needs TX? Should there not have been a control group with the same matched pre-morbid function and outcomes compared, vs TX received by both groups to make that claim? I do not see this going on in this study nor have I seen it in any study. I have no idea in the long term if those we call schizophrenic are better or worse off because of the TX they receive in the US. WHO data would seem to indicate they are worse off. Again thanks for your efforts.

NeuroPsych said...

Dr. John,
I wasn't answering "yes" based on the reviewed studies. I was saying "yes" due to the severity of the disorder in general and the generally low functioning of individuals with this disorder.

Based on these two reviews, one could argue that current treatments are not very effective, as many patients were chronically symptomatic while receiving treatment, and the minority that did well had various premorbid factors that contributed to that success instead of medications.

Also, "treatment" for this disorder goes well beyond medications, as many psychosocial interventions are also necessary to maximize functioning.

I tend to agree with what was said in the comment above yours, that meds for acute episodes are prudent, but beyond that, there true utility is still nebulous (I also would argue that the same is true for bipolar disorder).

Anonymous said...

Let's face it: In Psychiatry, a diagnosis of schizophrenia is equivalent to being diagnosed with Stage 4 cancer or Alzheimer's disease. Strong medications are needed but they are psychiatric chemotherapy. The meds have horrific side effects and much like chemo, run the risk of killing the host (i.e. brain) to paradoxically "cure" it. But we don't "cure" anyone with schizophrenia. It makes a lot of sense that those patients who, for whatever premorbid, social, and/or developmental reasons, can endure without meds should do so and save their brains. Of course, we need better medication without these side effects. But Big Pharma's mantra to the effect that everyone needs to take these meds forever should be questioned in light of Harrow's work. This is hardly candy that is being dispensed!

NeuroPsych said...

It's fitting that you refer to it as "psychiatric chemotherapy," because that is the direction that Stephen Stahl recommends that treatment should head:

"Psychopharmacological treatments for schizophrenia in the future will need to borrow a chapter out of the book of cancer chemotherapy and HIV/AIDS therapy, where the standard treatment is to use multiple drugs simultaneously to attain therapeutic synergy." pg. 450.

Anonymous said...

This post needs a dose of "human". In my experience, a schizophrenia diagnosis has not been akin to stage 4 cancer. Treatment extends far beyond antipsychotics and those who are committed to their recovery and have the support network to facilitate recovery live fairly normal lives. The disease isn't a death sentence. It's not seasonal depression, sure, but with cognitive therapy and the least effective dose of meds possible, reintegration after a psychotic episode and recovery thereafter is possible. Having a loving spouse and accepting family has been key in my situation.

Anonymous said...

Anonymous: I agree fully with you. Outcome can (and is) heavily influenced by factors such as family support and social integration. That's why, in part, schizophrenics apparently do better in third world and developing nations, where they have more family support and there is much less stigma attached to having psychotic episodes, which appears to reflect larger cultural beliefs about the "normalcy" of demonic possessions, etc. Also, you may be like those Harrow study subjects who had better premorbid developmental and social adjustment. You do seem to agree that the less medication needed, the better you will be in the long term. I am not anti-meds; it is just a fact that these agents also have long term side effects that are deleterious to long term functional outcome. Again, we need better medications to treat this horrible disease. Finally, I stand by my earlier characterization about schizophrenia, for most (but not all) people, being a very ominous diagnosis. And that's also what the Harrow study says.

Anonymous said...

Why don't you ask people with SZ like me. I can tell you with out medication I would be in serious trouble. These people do these studies and they preach against medication which in turn gives us, who hate the side affects, a reason to stop taking them. Then we relapse and end up back in the hospital. I'm sure there are some that can recover from this but the majority can't and we need medication to function.

Anonymous said...

Anonymous (17 December, 2010): Though I'm sure you won't read this, and I'll probably never see a reply, I would like to chime in. I began having symptoms in 1995 and had my first "break" in 1996. Anyway; I sought help and endured a few years of medication(s). I took Haldol, Risperdal, Cogentin, Zyprexa, Zoloft, Seroquel, and some I can't even remember due to being heavily sedated; basically "whatever the doctor ordered". The Seroquel was the last one I took, and it did seem to help, but after a year I was feeling stable enough to (slowly) withdraw the medication. And so I did. Here I am, ten years later, with no "relapses" and only minor -- and very rare -- symptoms (all of which seem to be caused by stress or lack of sleep). I must admit that I have an excellent "support system" and I couldn't have come this far without those friends and family members. Sure; I'm still taking the dole (which I don't like and never have) but I truly need it and it's due more to my back than "SZ" now. I was doing great (and was self-employed) before my back gave out (after a series of injuries). Anyway; I really do hope that I'm not, as you claim, in the minority. But we must be stronger than our "delusions" and it's absolutely imperative to have at least one person in your life who you can trust to "talk you down" before they get out of hand. I wish you (and all fellow "schizophrenics") the best of luck (and I truly mean this because I know it can be a literal Hell on Earth) with your recovery. May your remission be permanent and may all of your "delusions" f**k off back to the neurological netherworld from whence they originated...

beermuff said...

Correct me if I'm reading the charts wrong, but on the chart of patients with favorable prognostic indices it says 55% of the patients who experienced some recovery and were not on meds had favorable prognostic indices. Does that mean that 45% of the patients who were not on meds and experienced some recovery had poor prognostic indices (I was wondering the same thing about the chart for premorbid developmental achievement)? That seems like a significant percentage, one that makes me wonder what kind of treatment they were receiving (if any) in place of meds or meds with therapy.