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
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.
Available from: Joseph Peuskens
- "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.
- "In all cases, the available validated translated instruments were used. Whilst there is currently no consensus as to the operational criteria and definition of recovery in schizophrenia, previous literature has indicated that measures should be multidimensional and include clinical remission (maintained over a 6-month period) and social outcomes (Emsley et al., 2011; Andreasen et al., 2005). As such, recovery was defined per-protocol as PANSS Positive Symptom Factor Score b 28, PANSS Negative Symptom Factor Score b 20 and Personal and Social Performance (PSP) score ≥ 80 for at least the previous 6 months. "
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The high societal burden of schizophrenia is largely caused by the persistence of symptoms and accompanying functional impairment. To date, no studies have specifically assessed the course of persistent symptoms or the individual contributions of positive and negative symptoms to patient functioning. The cross-sectional analysis of the Pattern study provides an international perspective of the burden of schizophrenia.
Clinically stable outpatients from 140 study centers across eight countries (Argentina, Brazil, Canada, France, Germany, Italy, Spain and the United Kingdom) were assessed using clinical rating scales: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Personal and Social Performance (PSP) Scale. Additional measures included patient-reported outcomes, patient socio-demographic variables, living situation, employment and resource use.
Overall, 1379 patients were assessed and analyzed and had similar sociodemographic characteristics across countries, with 61.6% having persistent positive and/or negative symptoms. Positive and negative symptoms had been persistent for a mean of 9.6 and 8.9years (SD: 8.8 and 9.6), respectively. Approximately 86% of patients had a functional disability classified as greater than mild. Patients with a higher PANSS Negative Symptom Factor Score were more likely to have a poorer level of functioning.
This analysis examines individual contributions of persistent positive and negative symptoms on patient functioning in different countries. A high prevalence of patients with persistent symptoms and functional impairment was a consistent finding across countries. Longitudinal observations are necessary to assess how to improve persistent symptoms of schizophrenia and overall patient functioning.
Available from: Sergey Nikolaevitch Mosolov
- "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.
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