Is going into stable symptomatic remission associated with a more positive development of life satisfaction? A 10-year follow-up study of first episode psychosis
Introduction
Over the last decades, the heterogeneity of long-term outcome in schizophrenia and related psychotic disorders has become increasingly clear. Some patients experience continuous symptoms of psychosis, while others develop stable symptomatic remission (Andreasen et al., 2005, Emsley et al., 2007, Lambert et al., 2008, Wunderink et al., 2009, Hegelstad et al., 2013, Austin et al., 2013). The most commonly used definition of remission today is based on the criteria proposed by The Remission in Schizophrenia Working Group (RSWG) (Andreasen et al., 2005). According to these criteria, being in remission is characterized by lack of both positive symptoms (e.g. hallucinations, delusions and disorganization), and negative symptoms (e.g. blunted affect and avolition) over the last six months (the time criterion). As such, the criteria do not include affective symptoms, substance use problems and other important aspects such as daily life functioning and quality of life (QoL).
QoL is most commonly conceptualized as having both an objective part reflecting socio-economic factors, and a subjective part (S-QoL) reflecting life satisfaction (Katschnig, 2000, Malla and Payne, 2005, Karow et al., 2014, Eack and NewHill, 2007). Life satisfaction is an aspect transcending both symptoms and functioning, and thus a central part of outcome in chronic disorders. We have recently shown that socio-economic factors like more family contact, better financial situation and more daily activities are important for a positive S-QoL-development the first 10 years after a first episode psychosis (FEP) (Gardsjord et al., 2016). Regarding psychiatric symptoms, S-QoL has been shown to be most consistently associated with general psychopathology such as depressive symptoms, while positive psychotic symptoms are probably of less importance (Eack and NewHill, 2007, Priebe et al., 2011).
Previous longitudinal FEP-studies investigating the association between S-QoL and symptomatic remission show mixed results. Both Boden et al. (2009) and Jaracz et al. (2015) found remission at follow-up associated with higher S-QoL-level. In the study by Jaracz et al. (2015), the difference in S-QoL between remission and non-remission was stable over the follow-up period. Hence, one cannot conclude from the study that going into remission is associated with a more positive S-QoL-development. The same applies to the study by Boden et al. (2009) as only data from the follow-up assessment were collected. These studies didn't apply the time criterion when defining remission. Wunderink et al. (2007), applying the time criterion, found a small increase in S-QoL from baseline to follow-up regardless of remission status and no association between remission status and S-QoL at follow-up. This study included patients in remission from positive psychotic symptoms at baseline, and is therefore less suitable to investigate if going into stable remission is associated with a more positive S-QoL-development. To sum up it is unclear if going into stable remission is associated with a more positive S-QoL-development. A follow-up study of FEP included at first treatment is suitable for addressing this question.
Given the heterogeneity in outcomes, patient characteristics associated with S-QoL may be different among patients in remission and non-remission. This has not been investigated according to criteria proposed by the RSWG. In addition, stable remission of symptoms is not necessarily associated with adequate functioning/full recovery (Hegelstad et al., 2012). The impact this has on life satisfaction has not been investigated before.
In the present study we address the knowledge gap described in the previous paragraphs. We aimed to investigate;
- 1)
if being in stable symptomatic remission was associated with a higher life satisfaction at 10-year follow-up,
- 2)
if being in full recovery is associated with higher life satisfaction compared to patients in remission, but not in full recovery
- 3)
if patients that go into stable symptomatic remission show a more positive development of life satisfaction compared to non-remission,
- 4)
associations between life satisfaction and psychiatric symptoms, socio-economic factors and substance use problems at 10-year follow-up in groups according to remission status.
Section snippets
The TIPS study
The TIPS (Early Treatment and Intervention of Psychosis) study is a large prospective FEP-study of clinical, epidemiologic samples from four Scandinavian catchment areas. Patients were assessed with a large clinical battery at baseline, and reassessed after one year, two years, five years and 10 years. Reliability has been shown to be good for symptoms and diagnosis. The study is more thoroughly described elsewhere (Melle et al., 2004, Hegelstad et al., 2012).
Study subjects
In total 301 individuals with a
Results
Sample characteristics at 10-year follow-up are shown in Table 1. Individuals in remission showed less symptoms across all PANSS components, had higher GAF-scores, less drug use problems, more daily activities and more social contact. S-QoL were significantly higher among individuals in remission compared to patients in non-remission (t = 4.0, p < 0.01). Individuals in full recovery reported higher life satisfaction compared to the patients in remission, but not in full recovery (t = 2.25, p = 0.03).
Discussion
The main finding in the present study was that individuals with first-episode psychosis going into stable symptomatic remission have a more positive S-QoL-development. Different symptoms seem important for S-QoL depending on remission status.
In contrast to previous studies investigating the association between S-QoL and remission status, all participants included in the present study were in non-remission at first assessment. The two groups defined by remission status at follow-up did not
Conflict of interest
All authors declare that they have no conflicts of interest.
Contributors
Authors SF, TM, IM, PV, SO, BRR, JIR, JOJ, TKL, IJ, ES and UH took part in designing the study. Authors ESG, KLR, JIR and SF undertook the statistical analysis of this particular study. Author ESG wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Role of funding source
The project has been approved by the Regional Committee for Medical Research Ethics Health Region II (#S-95189) and the Regional Committee for Medical Research Ethics Health Region East (#1.2007.2177).
Data Inspectorate (License #96/3017-2 and #2003/2052).
Biological data collection approved by Norwegian Directory of Health (#200403453) and the Regional Committee for Medical Research Ethics Health Region East (#493-03-01179). The Regional Committee for Science Ethics region Sjælland, Denmark
Acknowledgment
Many thanks to all the patients who have contributed to this study.
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