Am J Psychiatry 162:9, September 2005
LETTERS TO THE EDITOR
such trials, the expectations about the benefits of ECT for the
treatment of depression in patients with borderline personal-
ity disorder have to be realistic: ECT alone is unlikely to be a
“magic bullet,” and additional interventions, including psy-
chotherapy (e.g., dialectical behavior therapy ) and phar-
macological treatments, are likely needed to achieve clinically
meaningful and sustained improvement for the complex
symptoms faced by this population.
1. Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Petti-
nati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J: Contin-
uation pharmacotherapy in the prevention of relapse follow-
ing electroconvulsive therapy: a randomized controlled trial.
JAMA 2001; 285:1299–1307
2. Linehan MM: Cognitive-Behavioral Treatment of Borderline
Personality Disorder. New York, Guilford, 1993
ULRIKE FESKE, PH.D.
BENOIT H. MULSANT, M.D.
PAUL A. PILKONIS, PH.D.
PAUL SOLOFF, M.D.
DIANE DOLATA, M.S.W.
HAROLD A. SACKEIM, PH.D.
ROGER F. HASKETT, M.D.
Sustained Remission of Schizophrenia
TO THE EDITOR: In their article on sustained remission of
schizophrenia in older outpatients, Dilip V. Jeste, M.D., and
Lisa A. Auslander, Ph.D. (1), matched 12 patients with sus-
tained remission with 12 still-symptomatic schizophrenia pa-
tients and 12 normal comparison subjects. Their finding of no
statistical differences on a composite measure of neurocogni-
tive functioning between the schizophrenia patients who
were or were not in sustained remission was viewed as an ex-
ample of the persistence of neurocognitive deficits even in
patients whose symptoms were low or nil. In their article, they
did not specify the criteria used for defining sustained remis-
sion in terms of quantitative levels of symptoms, nor did they
report the age-appropriate, psychosocial functional status of
the patients, such as peer relations, independent recreational
activities, employment or volunteer work, or the ability to live
without supervision of finances and medication manage-
ment. Because neurocognitive capacities are known to be
much more related to psychosocial functioning than to symp-
toms, it is important to include personal functioning in stud-
ies relating neurocognition to good outcomes.
In a study using the same design, we matched 28 middle-
aged schizophrenia patients who were in sustained remission
and living independently for 2 years or more with 28 still-
symptomatic schizophrenia patents and 28 normal compari-
son subjects. To meet our criteria for sustained remission, or
recovery, we required the patients to score 4 or less on the
Brief Psychiatric Rating Scale, to work or attend school at least
half-time, to live independently (without supervision of their
finances and medication management), and to have at least
one social activity per week with a peer without professional
We found that neurocognitive performance on tests tapping
executive functioning, verbal fluency, and verbal working
memory was the same for the recovered schizophrenic patients
and their matched normal comparison subjects and signifi-
cantly better than that of the still-symptomatic patients (2).
The only cognitive functioning that remained significantly dif-
ferent between the recovered patients and the normal subjects
was early visual processing, as measured by the Forced-Choice
Span on Apprehension Test (3), which is viewed as an enduring
vulnerability or “trait marker” for schizophrenia.
Because the criteria for sustained remission and psychoso-
cial functioning were not specified in the article by Drs. Aus-
lander and Jeste, it was not possible to compare the results
with our study strictly; however, it is worth pointing out that
the article by Drs. Auslander and Jeste 1) collapsed their neu-
rocognitive tests into a global index and 2) used statistical
tests with a tiny sample to determine mean differences be-
tween the groups on neurocognitive, quality of life, and social
functioning rather than evaluating differences between sub-
samples that achieved or did not achieve categorical defini-
tions of symptomatic and functional recovery.
If Drs. Auslander and Jeste could assign specific criteria to
their definitions of “sustained remission” or “psychosocial
functioning,” it might be possible to determine how many of
their small group actually achieved an operationalized con-
struct of recovery that might reflect differences in neurocog-
nition between recovered and nonrecovered patients. Identi-
fying neurocognitive and other malleable predictors and
correlates of optimal clinical improvement and recovery can
contribute to a growing database that would be relevant for
targeting treatment interventions with resultant improve-
ments in services for persons with schizophrenia (4).
We are delighted that other investigators have begun to de-
velop criteria for recovery from schizophrenia and are con-
ducting research on this elusive but much-desired outcome.
We agree with Drs. Auslander and Jeste that patients with
schizophrenia would have considerably greater opportunities
for recovery if systems of care provided services that offered
combined comprehensive, continuous, coordinated, com-
passionate, consumer-oriented, and evidence-based psycho-
1. Auslander LA, Jeste DV: Sustained remission of schizophrenia
among community-dwelling older outpatients. Am J Psychiatry
2. Kopelowicz A, Liberman RP, Ventura J, Zarate R, Mintz J: Neu-
rocognitive correlates of recovery from schizophrenia. Psychol
Med (in press)
3. Nuechterlein KH, Dawson ME, Ventura J, Gitlin M, Subotnik KL,
Snyder KS, Mintz J, Bartzokis G: The vulnerability/stress model
of schizophrenic relapse: a longitudinal study. Acta Psychiatr
Scand Suppl 1994; 382:58–64
4. Hogarty GE, Flesher S, Ulrich R, Carter M, Greenwald D, Pogue-
Geile M, Kechavan M, Cooley S, DiBarry AL, Garrett A, Parepally
H, Zoretich R: Cognitive enhancement therapy for schizophre-
nia: effects of a 2-year randomized trial on cognition and be-
havior. Arch Gen Psychiatry 2004; 61:866–876
ROBERT PAUL LIBERMAN, M.D.
ALEX KOPELOWICZ, M.D.
Los Angeles, Calif.
Dr. Jeste and Colleagues Reply
TO THE EDITOR: We thank Drs. Liberman and Kopelowicz for
their interest in our article and for their comments. We wish
to clarify several issues raised. We employed the following