The concepts of remission and recovery in schizophrenia

Department of Psychiatry, University of Stellenbosch, Tygerberg Campus, Cape Town, South Africa.
Current opinion in psychiatry (Impact Factor: 3.94). 03/2011; 24(2):114-21. DOI: 10.1097/YCO.0b013e3283436ea3
Source: PubMed


Until recently outcome studies in schizophrenia lacked standardized measures, and outcome expectations were generally pessimistic. The Remission in Schizophrenia Working Group (RSWG) published operationalized criteria for symptomatic remission in 2005. These criteria have been extensively applied in research settings and have stimulated research into other components of outcome, particularly functional outcome and quality of life. Attention has also shifted beyond remission to the more difficult to attain and complex concept of recovery. The purpose of this review is to examine recent studies on these topics and to assess whether progress has been made towards a broader definition of remission and recovery.
Reported remission rates vary widely across studies (17-88%). Patients in remission do better than their nonremitted counterparts in several other outcome domains. Predictors of remission include early treatment response, and baseline symptom severity and subjective well being. Patients move in and out of remission over time. At present, there is no consensus on methods of measuring other outcome domains, particularly functional status and quality of life.
The RSWG remission criteria are easy to apply and define an achievable and desirable treatment goal. Measures of social and occupational functional outcome, quality of life and cognitive status need to be further developed and standardized before remission and recovery criteria can be more broadly defined.

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    • "In this context, it would be interesting to know whether consistent, once-daily, oral intake of an effective and well-tolerated antipsychotic medication can contribute to long-term efficacy and relapse prevention [Emsley et al. 2011]. "
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    ABSTRACT: This study was designed to explore the efficacy and tolerability of oral paliperidone extended release (ER) in a sample of patients who were switched to flexible doses within the crucial first 5 years after receiving a diagnosis of schizophrenia. Patients were recruited from 23 countries. Adults with nonacute but symptomatic schizophrenia, previously unsuccessfully treated with other oral antipsychotics, were transitioned to paliperidone ER (3-12 mg/day) and prospectively treated for up to 6 months. The primary efficacy outcome for patients switching for the main reason of lack of efficacy with their previous antipsychotic was at least 20% improvement in Positive and Negative Syndrome Scale (PANSS) total scores. For patients switching for other main reasons, such as lack of tolerability, compliance or 'other', the primary outcome was non-inferiority in efficacy compared with the previous oral antipsychotic. For patients switching for the main reason of lack of efficacy, 63.1% achieved an improvement of at least 20% in PANSS total scores from baseline to endpoint. For each reason for switching other than lack of efficacy, efficacy maintenance after switching to paliperidone ER was confirmed. Statistically significant improvement in patient functioning from baseline to endpoint, as assessed by the Personal and Social Performance scale, was observed (p < 0.0001). Treatment satisfaction with prior antipsychotic treatment at baseline was rated 'good' to 'very good' by 16.8% of patients, and at endpoint by 66.0% of patients treated with paliperidone ER. Paliperidone ER was generally well tolerated, with frequently reported treatment-emergent adverse events being insomnia, anxiety and somnolence. Flexibly dosed paliperidone ER was associated with clinically relevant symptomatic and functional improvement in recently diagnosed patients with non-acute schizophrenia previously unsuccessfully treated with other oral antipsychotics.
    Therapeutic Advances in Psychopharmacology 05/2015; 5(4). DOI:10.1177/2045125315584870 · 1.53 Impact Factor
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    • "Our recent study from a city outpatient schizophrenia sample has shown that the majority of patients with a stable symptomatology and chronic illness course (about 80%) do not achieve the suggested IRC. This remains the case, even after switching to treatment with a more modern long-acting atypical antipsychotic (RLAI).25 Results of this study concur with the Wobrock et al34 data; that is to say, that paranoid schizophrenia patients with episodic or remittent courses are more likely to meet the IRC than patients with other ICD10 diagnosis types (for example, residual schizophrenia), as well as with the data of other investigators, who indicated that symptoms such as depression, illness insight, cognitive impairment, and, most essentially, level of social functioning, should be considered in remission criteria.17,20,35,42,43 Otherwise, for most chronic patients in stable status, clinically evaluated by the attending psychiatrist as to their possible remission, the symptomatic IRC threshold is not met. "
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    ABSTRACT: International Remission Criteria (IRC) for schizophrenia were developed recently by a group of internationally known experts. The IRC detect only 10%-30% of cases and do not cover the diversity of forms and social functioning. Our aim was to design a more applicable tool and validate its use - the Standardized Clinical and Functional Remission Criteria (SCFRC). We used a 6-month follow-up study of 203 outpatients from two Moscow centers and another further sample of stable patients from a 1-year controlled trial of atypical versus typical medication. Diagnosis was confirmed by International Classification of Diseases Version 10 (ICD10) criteria and the Mini-International Neuropsychiatric Interview (MINI). Patients were assessed by the Positive and Negative Syndrome Scale, including intensity threshold, and further classified using the Russian domestic remission criteria and the level of social and personal functioning, according to the Personal and Social Performance Scale (PSP). The SCFRC were formulated and were validated by a data reanalysis on the first population sample and on a second independent sample (104 patients) and in an open-label prospective randomized 12-month comparative study of risperidone long-acting injectable (RLAI) versus olanzapine. Only 64 of the 203 outpatients (31.5%) initially met the IRC, and 53 patients (26.1%) met the IRC after 6 months, without a change in treatment. Patients who were in remission had episodic and progressive deficit (39.6%), or remittent (15%) paranoid schizophrenia, or schizoaffective disorder (17%). In addition, 105 patients of 139 (51.7%), who did not meet symptomatic IRC, remained stable within the period. Reanalysis of data revealed that 65.5% of the patients met the SCFRC. In the controlled trial, 70% of patients in the RLAI group met the SCFRC and only 19% the IRC. In the routine treatment group, 55.9% met the SCFRC and only 5.7% the IRC. Results of the further independent sample demonstrated that 35% met the IRC, 65% the SCFRC, and 56% of patients met both the symptomatic and functional criteria. In the controlled trial of RLAI and olanzapine, 40% and 35% of patients, respectively, met the IRC, while 70% and 55%, respectively, met the SCFRC. In schizophrenia outpatients, a greater proportion of stable cases is detected in remission by SCFRC in comparison with IRC. The SCFRC were more sensitive to the full spectrum of schizophrenia. The SCFRC appear to be valid as a tool and clinically useful as they produce a comprehensive assessment of treatment effectiveness for a wide range of patients.
    Neuropsychiatric Disease and Treatment 01/2014; 10:167-81. DOI:10.2147/NDT.S46799 · 1.74 Impact Factor
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    • "As PANSS scale provides ratings investigating not only symptom severity per se but also functional impairment, a score of “mild” or better (i.e. 3 points or less) at all eight “core” symptoms was considered sufficiently representative of a level of impairment consistent with symptomatic remission of the disorder [7]. According to recent reviews [8,9] reported remission rates vary widely across studies (17-88%), likely due to use of symptom severity criterion alone in the majority of studies [9]. A number of studies have demonstrated the validity of these remission criteria using two different approaches, namely comparison of different definitions of symptomatic remission and association of remission criteria with various outcome dimensions, mainly overall symptomatic status and functional outcome [10]. "
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    ABSTRACT: This study aims to compare severity criteria defined by the Remission in Schizophrenia Working Group (RSWGcr) with other criteria in relation to functional and neurocognitive outcome. 112 chronic psychotic outpatients were examined. Symptomatic remission according to RSWGcr was compared with the outcome achieved using criteria based on PANSS Positive and Negative Scales (PANSS-PNScr) and the entire PANSS (PANNS-TScr). Remission rates were 50%, 35% and 23% respectively at RSWGcr, PANSS-PNScr and PANNS-TScr; functional remission rates were 32%, 42% and 54%. Sensitivity, specificity, predictive value and ROC analysis demonstrated the superiority of PANSS-PNScr in identifying patients with higher functional and cognitive outcomes. Regression analysis showed a significant predictive effect of PANSS-TScr on functioning. General linear model analyses demonstrated significantly higher mean scores at PSP and BACS for patients remitted according to PANSS-TScr. The use of more restrictive severity criteria of remission seems to be associated with improved identification of truly remitted patients.
    BMC Psychiatry 09/2013; 13(1):1-10. DOI:10.1186/1471-244X-13-235 · 2.21 Impact Factor
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